Remote DRG Coding & Clinical Validation Analyst

Excellus BlueCross BlueShield; Town of De Witt (NY); Hybrid; USD 65,000 - 145,000; Full time

Job summary

Excellus BlueCross BlueShield is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with extensive experience in acute facility-based clinical documentation and inpatient coding. The role focuses on reviewing medical records to support principal diagnosis, co-morbidities, and procedures to validate DRG accuracy and hospital data integrity.

You will apply ICD-10/DRG guidelines, ensure regulatory compliance, and lead complex audits while mentoring teammates and collaborating with

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: RHIA or RHIT, Inpatient Coding Credential – CCS or CIC.
• Intermediate analytical and problem-solving skills; knowledge of PC, software, auditing tools and claims processing systems.

Responsibilities

• Analyzes and audits acute inpatient claims and applies ICD-10/DRG principles.
• Adheres to official coding guidelines and CMS requirements; maintains expert DRG/ICD-10 knowledge.
• Establishes national benchmarks and measures performance against them.
• Ensures accurate payment using DRG grouper, encoder, and claims processing platform.
• Manages case volumes and audit schedules; supports management priorities.
• Mentors new hires and participates in cross-functional initiatives.
• Provides leadership in complex audits and client-facing initiatives.
• Delivers training and coaching to team members on continuous quality improvement.

Skills

ICD-10 coding expertise

DRG coding knowledge

Auditing and quality assurance

Regulatory compliance

Analytical problem solving

Education

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

Coding Certifications (RHIA/RHIT or CCS/CIC)

Tools

DRG grouper

Encoder

Claims processing systems

Job description

Excellus BlueCross BlueShield is seeking a Payment Integrity DRG Coding & Clinical Validation Analyst with extensive experience in acute facility-based clinical documentation and inpatient coding. The role focuses on reviewing medical records to support principal diagnosis, co-morbidities, and procedures to validate DRG accuracy and hospital data integrity.

You will apply ICD-10/DRG guidelines, ensure regulatory compliance, and lead complex audits while mentoring teammates and collaborating with