DRG Validator

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Job Summary

The Diagnosis Related Group (DRG) Validator, is responsible for reviewing inpatient coded records records in accordance with Uniform Hospital Discharge Data Set (UHDDS) Definitions to validate an inpatient admit order, assignment of and sequencing of ICD-10-CM/PCS principal and secondary diagnoses, principal and secondary procedures, the discharge disposition codes and the DRG Assignment. Solid knowledge of MS-DRG, APR-DRG (SOI/ROM), Coding Guidelines, American Hospital Association (AHA) Coding Clinic and Present on Admission (POA) Indicator Guidelines. All HACs, PSIs and focused MS-DRGs are identified by PWC SMART Application. Collaborates with Quality Department for 2nd Level quality review of all Hospital Acquired Conditions (HACs) and selected AHRQ Patient Safety Indicators (PSIs). Works with Clinical Documentation Improvement (CDI) Manager, upon request will performs 2nd level review of identified cases for appropriate assignment of Severity of Illness (SOI) and Risk of Mortality (ROM) utilizing the APR-DRG. Performs chart review for DRG Claim Review Requests and determine correctness of original vs. recommended MS-DRG. The DRG Validator assists the Coding Manager with identifying coding trends for education based on audit findings. As needed, performs inpatient coding of accounts.

RESPONSIBILITIES:

• Performs daily coding reviews for HACs, selected PSIs and focused DRGs on inpatient records identified by SMART to validate the assigned ICD-10 CM/PCS Codes and Present of Admission (POA) assignment.
• Send notifications to the Quality Department (Quality Reviewer) to conduct a Quality Level review on cases in which the PSI/HAC Diagnosis and/or POA indicators are in alignment with documentation.
• Reviews selected records, validating secondary diagnoses and procedures to ensure compliance with all reporting requirements.
• Ability to write concise rationale to support audit findings and DRG Claim Review Appeal letters, referencing applicable official guidelines, when applicable.
• Evaluates the quality of clinical documentation to identify incomplete or ambiguous documentation for inpatient encounters that impact the code selection and resulting DRG assignment and reimbursement.
• Utilizing SMART Tool, ability to perform data analysis and identify trends for Coding/CDI opportunities and provide feedback to assure coding uniformity, consistency and accuracy with ICD-10-CM/PCS.
• Works closely with the Clinical Documentation Improvement Manager in pre-bill review of Mortality charts and Hospital Acquired Conditions (HACs), and specific diagnosis or DRG's as assigned.
• Collaborates with the Coding Vendor to provide input for development of educational areas for inpatient coding involving both internal and external training.
• Works jointly with Independent Coding Auditor regarding recommendations for revisions to diagnoses and/or procedures, queries and HIM DRG spreadsheet.
• Works with Executive Director of HIM and Corporate Coding & Reimbursement Manager to develop process improvements to maintain data quality.
• As needed, assist with coding of accounts.
• Completes special projects as assigned, other duties as assigned.

QUALIFICATIONS:

2 years Auditing experience or strong training background in coding and reimbursement.

5 years Progressive inpatient coding in an acute care hospital and coding review experience in ICD-10-CM/PCS.

Claims processing and/or data management responsibilities, a plus. Experience with Epic System, a plus

EDUCATION:

BA Health Administration

CERTIFICATIONS:

MGNT-Certified Coding Specialist - AHIMA - American Health Information Management Association

Registered Health Information Technician - AHIMA - American Health Information Management Association

Certified Clinical Documentation Specialist (CCDS)

Certified Documentation Improvement Practitioner (CDIP)

Core Competencies

These competencies reflect the values and behaviors expected of all Grady team members, regardless of role. They ensure that every employee contributes to safe, high-quality care, positive patient experience, and a collaborative work environment.

1. Patient-Centered Care - Demonstrates a commitment to delivering safe, compassionate, and high-quality care that prioritizes the well-being and satisfaction of patients and their families.

2. Integrity & Accountability - Acts ethically, maintains confidentiality, and accepts responsibility for actions, decisions, and outcomes.

3. Collaboration & Teamwork - Builds positive relationships, works effectively across departments, and supports colleagues to achieve shared goals.

4. Communication - Communicates clearly, respectfully, and effectively with patients, families, colleagues, and leadership.

5. Respect & Inclusion - Creates an inclusive environment by valuing diversity, treating others with dignity, and ensuring equitable care and opportunities for all.

6. Quality & Safety - Adheres to best practices, regulatory standards, and policies to ensure safe, reliable, and high-quality outcomes.

7. Adaptability & Resilience - Responds effectively to change, remains flexible in dynamic situations, and demonstrates resilience under pressure.

8. Continuous Improvement - Seeks opportunities to improve processes, skills, and outcomes through innovation, learning, and feedback.

9. Leadership & Professionalism - Inspires, guides, and develops individuals and teams while modeling professionalism, fairness, and transparency.

10. Employee Experience Focus - Champions a supportive and engaging employee journey that enables staff to thrive and, in turn, deliver exceptional patient care.

Grady Total Rewards

At Grady, we believe in supporting the health, well-being, and growth of every team member. Our Total Rewards package is designed to provide competitive pay and comprehensive benefits that make a difference in your life and career, including:

• Health & Wellness: Medical, dental, vision, and prescription drug coverage.

• Financial Security: Retirement savings plans with employer contributions, life insurance, and disability coverage.

• Work-Life Balance: Paid time off, holidays, and family leave benefits.

• Career Growth: Tuition reimbursement, professional development programs, and opportunities for advancement.

• Employee Support: Employee Assistance Program (EAP), wellness initiatives, and discounts on services.

Grady's Total Rewards are designed to ensure our employees feel valued, supported, and empowered, both at work and beyond.

Why Join Grady?

Grady Health System is more than a hospital - we are a vital part of Atlanta and the surrounding communities. For over 125 years, Grady has been committed to providing exceptional care, advancing health equity, and making a difference in the lives of those we serve. When you join Grady, you become part of a team that values excellence, compassion, innovation, and collaboration.

Here, every role matters. Whether you provide direct patient care, support our operations, or lead teams, you play an important part in fulfilling our mission. We offer opportunities to learn, grow, and build a meaningful career in an environment where your contributions are recognized and valued.

At Grady, we don't just work, we make an impact.

Equal Opportunity Employer Statement:

Grady Health System is proud to be an equal opportunity employer. We are committed to fostering a workforce where all employees feel valued, respected, and empowered to succeed. We prohibit discrimination and harassment of any kind based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other legally protected characteristic.

Grady is dedicated to creating an accessible work environment and provides reasonable accommodations to qualified individuals with disabilities to ensure equitable opportunities for success.