DRG Dispute Reviewer

The DRG Dispute Reviewer is responsible for evaluating provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. This role requires advanced knowledge of MS-DRG and APR-DRG methodologies, clinical validation, coding guidelines, and payer policies. Using clinical and coding expertise, the reviewer independently assesses documentation to ensure audit decisions are accurate, defensible, and compliant. This position plays a vital role in supporting regulatory compliance, identifying and recovering overpayments, and promoting proper documentation and reimbursement practices across healthcare systems.

Duties and Responsibilities

• Dispute Review: Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.
• Medical Record Analysis: Review inpatient medical records, UB-04s, and documentation to ensure correct DRG assignment and adherence to coding, billing, and payment guidelines.
• DRG Validation: Apply clinical validation and coding principles to support or overturn DRG audit findings using MS-DRG and APR-DRG grouping logic.
• Written Justification: Prepare clear, concise, and evidence-based rationales to support determinations for clients, providers, or payers.
• Coding Expertise: Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.
• Clinical Judgment: Use clinical acumen to assess medical necessity, documentation sufficiency, and code assignment accuracy.
• Collaboration: Work closely with audit leads and team members to ensure consistency and quality in dispute resolutions.
• Quality & Productivity: Meet performance standards for accuracy, timeliness, and productivity in dispute review and audit completion.
• Compliance: Adhere to HIPAA guidelines, industry best practices, and AHIMA’s Standards of Ethical Coding.
• Client Communication: Participate in client meetings, including presenting audit results when required.
• Tool Utilization: Use proprietary audit platforms, encoders, and medical record systems efficiently and effectively.
• Other Duties: Perform additional tasks as assigned to support audit operations and client needs.

• Work from anywhere in the US! Machinify is digital-first.
• Top Medical/Dental/Vision offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary, 401(k) with company match
• Additional health and wellness benefits and perks
• Flexible and trusting environment where you’ll feel empowered to do your best work