DRG Coder

What You'll Do

• Review inpatient hospital records and assign accurate diagnosis and procedure codes
• Determine the appropriate MS-DRG or APR-DRG assignment based on coding and clinical documentation
• Conduct coding validation and auditing to ensure compliance with payer and regulatory requirements
• Identify documentation gaps and communicate opportunities to providers, hospitals, and Clinical Documentation Improvement (CDI) teams
• Analyze denials and underpayments related to coding and DRG assignment
• Support retrospective and concurrent reviews of high-cost admissions and outlier cases
• Collaborate with utilization management, case management, finance, and contracting teams to optimize reimbursement and cost containment
• Assist with internal and external audits, including RAC, Medicare Advantage, Medicaid, and commercial payer reviews
• Provide education and mentoring to coding staff and other stakeholders
• Monitor changes in coding guidelines, reimbursement methodologies, and regulatory requirements
• Prepare reports and summaries related to coding accuracy, financial impact, and audit findings
• Maintain confidentiality and compliance with HIPAA and company policies
• Other duties as assigned

Qualifications

• Associate’s degree in Health Information Management, Nursing, or related field 
• Have at least 5 years of inpatient coding experience
• Have at least  2 years of advanced DRG validation, auditing, or hospital reimbursement experience
• Certifications One or more of the following required: • CCS, RHIA, or RHIT from American Health Information Management Association • CIC or CPC from AAPC
• Have advanced knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG methodologies
• Proficiency in coding software, electronic medical records, and Microsoft Office applications

• Experience working with Medicare Advantage, Medicaid, and commercial health plans
• Experience in a delegated IPA, MSO, or managed care environment  
• Have a strong understanding of Medicare reimbursement and payer audit processes
• Ability to interpret complex clinical documentation
• Knowledge of utilization management, case management, and managed care operations
• Strong analytical, organizational, and problem-solving skills
• Ability to work independently and manage multiple priorities
• Excellent written and verbal communication skills. 

Environmental Job Requirements and Working Conditions

• This position is remotely based in the U.S. The home office is located at 600 City Parkway West 10th Floor, Orange, CA 92868.
• This role is required to attend occasional in-person meetings with internal departments and external providers/hospitals, training, or audit purposes. 
• The national target pay range for this role is between $33.00 - $38.00. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.