DRG Reviewer

About MedReview

MedReview is a leading provider of payment integrity solutions that help national and regional health plans promote population health, ensure payment accuracy, reduce administrative waste, improve provider relationships, and optimize financial performance. For more than four decades, MedReview has partnered with health plans, third-party administrators, and other healthcare organizations to deliver technology-enabled solutions that identify savings opportunities, drive operational efficiency, and improve healthcare outcomes.

The Opportunity

MedReview is seeking an experienced DRG Reviewer to join our Payment Integrity team. This role is responsible for analyzing inpatient medical records and claims to validate coding accuracy, ensure appropriate DRG assignment, and identify opportunities for reimbursement accuracy and savings. The DRG Reviewer applies advanced coding expertise, regulatory knowledge, and critical thinking skills to support high-quality claims review and payment integrity outcomes.

The ideal candidate will have extensive experience with acute inpatient coding, DRG validation, and healthcare reimbursement methodologies. This position requires strong analytical skills, exceptional attention to detail, and the ability to work independently in a fast-paced remote environment.

This is a fully remote position. Candidates must be available to work Eastern Standard Time (EST) business hours.

Key Responsibilities

DRG Validation and Coding Review

• Review and analyze inpatient medical records and claims to validate ICD-10-CM/PCS coding accuracy and appropriate DRG assignment.
• Apply Official Coding Guidelines, AHA Coding Clinic guidance, CMS regulations, and industry standards during claim reviews.
• Identify coding discrepancies, documentation concerns, and reimbursement opportunities.
• Ensure accurate application of MS-DRG and APR-DRG methodologies.
• Evaluate claims for potential payment integrity findings and support accurate reimbursement outcomes.

Clinical Documentation and Collaboration

• Identify cases requiring additional clinical review and collaborate with Physician Reviewers when appropriate.
• Interpret complex clinical documentation and coding scenarios.
• Support interdisciplinary review processes to ensure claim determinations are well-supported and defensible.
• Maintain compliance with organizational, regulatory, and client-specific review requirements.

Quality, Productivity, and Compliance

• Complete comprehensive claim reviews in accordance with departmental procedures and review guidelines.
• Maintain established productivity and quality benchmarks.
• Consistently achieve high levels of coding accuracy and review quality.
• Ensure all reviews are completed within required turnaround times.
• Participate in quality monitoring and continuous improvement initiatives.

Reporting and Documentation

• Document findings, rationales, and recommendations clearly and accurately.
• Maintain detailed and organized review records.
• Submit productivity and performance reporting as required.
• Adhere to confidentiality, HIPAA, and data security requirements.

Team Collaboration and Professional Development

• Participate in departmental meetings, training sessions, and educational activities.
• Stay current with coding updates, regulatory changes, and industry best practices.
• Maintain all required certifications and continuing education requirements.
• Support special projects and additional responsibilities as assigned.

Qualifications

Required Qualifications

• Current coding certification in one or more of the following:
  • Certified Coding Specialist (CCS)
  • Certified Inpatient Coder (CIC)
  • Registered Health Information Technician (RHIT)
• Minimum of 3 years of experience in acute inpatient coding, DRG validation, coding audits, or payment integrity review.
• Strong knowledge of ICD-10-CM/PCS coding guidelines and DRG methodologies.
• Experience applying Official Coding Guidelines, AHA Coding Clinic guidance, CMS regulations, and reimbursement policies.
• Proficiency with Microsoft Office applications, including Outlook, Word, and Excel.
• Strong analytical, organizational, and critical thinking skills.
• Excellent written and verbal communication abilities.
• Ability to work independently and efficiently manage multiple priorities in a remote environment.

Preferred Qualifications

• Experience in payment integrity, DRG auditing, or healthcare claims review.
• Experience with both MS-DRG and APR-DRG validation.
• Knowledge of payer reimbursement methodologies and claims operations.
• Bachelor's degree in Health Information Management, Healthcare Administration, Nursing, or a related field.
• Previous experience working remotely in a healthcare review environment.

What Success Looks Like

Within the first 12 to 24 months, this individual will:

• Consistently meet or exceed productivity and quality expectations.
• Maintain 95% or greater review accuracy.
• Deliver timely and accurate DRG validation reviews.
• Demonstrate expertise in coding guidelines, reimbursement methodologies, and payment integrity practices.
• Collaborate effectively with physician reviewers and operations leadership.
• Contribute to savings identification and reimbursement accuracy initiatives.
• Support continuous quality improvement efforts across the DRG Operations team.

Remote Work Requirements

• High-speed internet connection (100 Mbps recommended).
• Secure workspace that protects confidential and HIPAA-regulated information.
• Ability to work independently in a distraction-free environment.
• Ability to sit and work at a computer for extended periods of time.
• Availability during Eastern Standard Time (EST) business hours.

Compensation

Salary Range: $85,000 - $95,000 annually, commensurate with experience.

Benefits

• Comprehensive Medical, Dental, and Vision Coverage
• 401(k) with Employer Match
• Generous Paid Time Off and Paid Holidays
• Flexible Spending Accounts (FSA) and Commuter Benefits
• Professional Development and Continuing Education Support
• LinkedIn Learning Access and Ongoing Training Programs
• Employee Wellness Programs
• Collaborative and Mission-Driven Work Environment