Clinical Documentation Integrity DRG Validator, Managed Care Network

Responsible for improving the quality, completeness, and clinical accuracy of inpatient documentation and DRG assignment through targeted concurrent DRG validation. The Clinical Documentation Integrity Specialist II – DRG Validator reviews selected inpatient accounts generally more than 48 hours from admission that have not been DRG optimized, using integrated electronic health record workflows, technology-enabled review worklists, and analytics-informed prioritization to focus on cases with the highest documentation, clinical validation, and reimbursement risk. Focused review includes non-optimized DRGs, signs and symptoms DRGs, APR-DRGs with SOI/ROM of 1/1 where the clinical picture suggests higher acuity, local infection DRGs to evaluate for sepsis or systemic illness, sepsis DRGs without documented organ dysfunction or other required clinical indicators, and level-of-care versus DRG mismatch, such as ICU or step-down patients assigned minor DRGs or SOI/ROM 1/1.. Scope to include all inpatient payors. Uses analytics informed prioritization, AI assisted worklists, and DRG encoder logic including TruBridge where implemented. Supports Epic transition planning for CDI workflows with planned go live in July 2027.

Degrees:

MD/DO

Required Licenses and Certifications:

Certified Clinical Documentation Specialist (CCDS) or Certified Documentation Integrity Practitioner (CDIP).

Additional Qualifications:

International medical school graduate required.

Five years of recent adult, pediatric, obstetric, inpatient medical, surgical, and critical care experience required.

Strong knowledge of Medicare MS-DRG and Medicaid APR-DRG assignment, severity of illness, risk of mortality, clinical validation, denial vulnerability, and documentation integrity required.

Experience in concurrent inpatient chart review, DRG validation, collaboration with coding professionals, and use of integrated electronic health records, web-based applications, and technology-enabled review/analytics tools required.

Knowledge of official coding guidelines, AHA Coding Clinic, CMS guidance, payer clinical validation expectations, and compliant documentation clarification consistent with AHIMA–ACDIS query guidance required.

Experience using integrated electronic health records and CDI workflows, including readiness for transition from CDEOne to Epic CDI with planned go live in July 2027.

Experience with analytics, reporting, and AI assisted review prioritization tools preferred.

Familiarity with DRG encoder and DRG validation tools including TruBridge preferred.

Minimum Required Experience: 5 Years

Schedule: Full-time