Remote DRG Coding & Clinical Validation Analyst

CDPHP in; City of Rochester (NY); Remote; USD 65,000 - 142,000; Full time

Benefits offered by this job

Remote work on case-by-case basis

Job summary

CDPHP is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III in Rochester, NY. The role focuses on reviewing medical records to validate DRG assignments, ensuring documentation supports diagnoses, procedures, and POA indicators, and maintaining coding accuracy across CMS guidelines.

Levels I-III require RHIA/RHIT or CCS/CIC certification and experience with MS-DRG/APR-DRG, ICD-10CM, and related coding systems.

Qualifications

• Associate or bachelor's degree in health information management (RHIA or RHIT) or a Nursing Degree.
• Three (3) years' experience in claims auditing, quality assurance, or recovery auditing, of (MS/APR) DRG coding for hospital or other acute facility setting.
• Three (3) years of working experience with ICD 10CM, MS-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, medical necessity criteria, and coding terminology.
• Coding Certification is to be maintained as a condition of employment of one of the following: RHIA or RHIT, Inpatient Coding Credential - CCS or CIC.

Responsibilities

• Analyze and audit acute inpatient claims and apply ICD-10/DRG coding principles to validate data.
• Ensure adherence to official coding guidelines, CMS rules, and regulatory mandates.
• Manage case volumes and review/audit schedules and maintain high data integrity.
• Lead complex audits, mentor new hires, and represent department in internal/external committees.
• Provide expertise in data criteria development for audits and assist with continuous quality improvement.

Skills

Claims auditing

Quality assurance

MS-DRG coding

APR-DRG coding

ICD-10CM

Medical billing

Provider billing guidelines

Medical necessity criteria

Coding terminology

DRG grouper

Education

Health information management degree (RHIA/RHIT) or Nursing degree

Tools

DRG grouper

Encoder

Claims processing platform

Job description

CDPHP is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III in Rochester, NY. The role focuses on reviewing medical records to validate DRG assignments, ensuring documentation supports diagnoses, procedures, and POA indicators, and maintaining coding accuracy across CMS guidelines.

Levels I-III require RHIA/RHIT or CCS/CIC certification and experience with MS-DRG/APR-DRG, ICD-10CM, and related coding systems.