DRG Audit & Compliance Specialist

Jackson Health System; Miami (FL); On-site; USD 70,000 - 100,000; Full time

Job summary

Jackson Health System in Miami, FL seeks a Clinical Coding Audit Specialist, HIM to ensure DRG accuracy and regulatory compliance across the organization.

The role reviews DRG downgrades and payer denials, collaborates with CDI, coding, billing, and clinical teams, and supports appeals with detailed findings and recommendations.

Candidates typically have 5–7 years of related experience, an AHIMA or AAPC credential, and an Associate's degree; Florida RN license is a plus.

Qualifications

• 5–7 years of related experience.
• AHIMA (RHIA/RHIT/CCS/CDIP/CDEI), or AAPC (CPC/CIC/COC), or ACDIS (CCDS) certification required.
• Florida RN license is preferred.

Responsibilities

• Perform comprehensive reviews of DRG downgrades and payer denials to validate accuracy of clinical documentation and final coding.
• Validate DRG assignments per ICD 10 CM/PCS, CMS guidelines, UHDDS definitions, and policies.
• Prepare detailed findings and recommendations to support appeals when appropriate.
• Track appeals through all levels (first level, second level, external) and ensure compliance with Medicare regulations, OCE/MCE edits, LCD/NCDs.
• Provide coding expertise and documentation clarification to support appeal letters and reconsideration requests.
• Conduct internal audits of inpatient coding and DRG assignments for regulatory and payer compliance.
• Identify patterns of coding errors, documentation gaps, or compliance risks and elevate findings.
• Maintain audit logs, trends and opportunities for improvement.
• Participate in root cause analysis to reduce denials and strengthen compliance.
• Collaborate with CDI and coding teams to analyze DRG related denials and develop prevention strategies.
• Assist in developing training materials and best practice guidelines.
• Communicate audit results and compliance updates to leadership and operations.

Skills

Analytical skills

Communication skills

Stress management

Follow instructions

Independent judgment

Technology proficiency

Education

Associate's degree

Foreign physician preferred

Job description

Jackson Health System in Miami, FL seeks a Clinical Coding Audit Specialist, HIM to ensure DRG accuracy and regulatory compliance across the organization.

The role reviews DRG downgrades and payer denials, collaborates with CDI, coding, billing, and clinical teams, and supports appeals with detailed findings and recommendations.

Candidates typically have 5–7 years of related experience, an AHIMA or AAPC credential, and an Associate's degree; Florida RN license is a plus.