DRG Reviewer

Centene
Missouri
Workplace: RemoteFull timeUSD 70,100 - 126,200 annuallyFunction: Quality & Regulatory (Non-Software)Experience: 4+ yearsEducation: associatesSkills: ["Professional judgment","Discretion","Communication","Prioritization"]

Independently conduct comprehensive MS-DRG and APR-DRG coding and clinical documentation reviews to ensure accurate DRG assignment and reimbursement. Use advanced ICD-10-CM/PCS expertise to validate diagnoses, detect coding discrepancies (including upcoding), and interpret payer and regulatory requirements. Partner with the Medical Director on complex cases, produce audit findings with authoritative references, and consistently meet quality and productivity standards while supporting appeals and medical policy development.

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FursaFursa
Centene
Centene
1 day ago

DRG Reviewer

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Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 11 hours agoStatus: Live
Reposted: similar role first listed 1 month ago

Job Summary

Independently conduct comprehensive MS-DRG and APR-DRG coding and clinical documentation reviews to ensure accurate DRG assignment and reimbursement. Use advanced ICD-10-CM/PCS expertise to validate diagnoses, detect coding discrepancies (including upcoding), and interpret payer and regulatory requirements. Partner with the Medical Director on complex cases, produce audit findings with authoritative references, and consistently meet quality and productivity standards while supporting appeals and medical policy development.
Location: Missouri
Workplace: Remote
Employment Type: Full time
Job Function: Quality & Regulatory (Non-Software)
Seniority: Mid level

Key Responsibilities

  • •Independently conduct MS-DRG and APR-DRG coding and clinical validation reviews to ensure correct ICD-10-CM/PCS assignments and DRG reimbursement rules.
  • •Identify discrepancies such as coding errors or upcoding and evaluate claims and medical records for compliance with state/federal regulations, payer contracts, and company policies.
  • •Collaborate with the Medical Director on complex cases and provide expert recommendations for DRG validation reviews and appeals.
  • •Prepare clear, well-supported audit findings using authoritative references such as AHA Coding Clinic, ICD-10 guidelines, and approved Centene policies.
  • •Meet quality and productivity standards, assist in developing audit concepts and selecting claims for review, and proactively identify opportunities for medical policy development.

Pay and Benefits

Salary: USD 70,100 - 126,200 annually
Equity and Bonus:Equity
Perks:Health Insurance401kEquityLearning BudgetPaid LeaveRemote Work

Key Requirements

  • •Associate's Degree in Health Information Management, Nursing, or a related field required.
  • •4+ years of experience performing MS-DRG and APR-DRG coding required.
  • •2+ years of experience performing DRG reviews for a Payment Integrity vendor or Payer required.
  • •2+ years of experience using DRG encoder/grouper tools (TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) required.
  • •RHIT, RHIA, CCS, CICP, or CCDS certification required, or RN licensure (with a coding credential) preferred.
Experience:4+ yearsPayment integrityPayer
Education:Associate's
Skills:Professional judgmentDiscretionCommunicationPrioritization
Licenses:RN
Certifications:RHITRHIACCSCICPCCDS
Tech Stack:MS-DRGAPR-DRGICD-10-CMICD-10-PCSAHA Coding ClinicTruCode/TruBridge3MOptum EncoderWebstratPSIICD-10 guidelines

Company Brief

Centene
Centene Corporation is a diversified, multinational healthcare enterprise that provides government-sponsored and commercial healthcare programs and services, specializing in Medicaid, Medicare, and specialty benefits management across the United States.
Industry: Health Insurance (Payers)
Company Size: Enterprise (1,001+ employees)
Revenue: USD 1B+
Growth: Public Company
Valuation: Public Company (Market Cap in USD)
Funding: IPO / Publicly Listed
Headquarters: St. Louis, United States
Founded: 1984
WebsiteLinkedIn