DRG Revenue Integrity Auditor

Job Title: DRG Revenue Integrity Auditor (Inpatient Coding Auditor)

Employment Type: Full-Time, Permanent

Salary Range: $90,000 – $110,000 per year

Schedule: Monday–Friday, regular business hours (flexible scheduling can be discussed during interviews)

Position Overview (Simple Explanation for Recruiters)

A DRG Revenue Integrity Auditor is a specialized medical coding expert who reviews hospital inpatient medical records. Their job is to make sure that the diagnosis and procedure codes assigned by hospital coders accurately reflect the care the patient received. Their work impacts hospital billing, compliance with federal regulations, and overall revenue integrity.

This role requires deep expertise in ICD-10-CM and ICD-10-PCS coding, DRG (Diagnosis Related Group) assignment, and clinical documentation review. Candidates will not be entry-level—they must have strong inpatient coding and/or auditing experience.

What This Role Does (Plain Language)

The DRG Revenue Integrity Auditor is responsible for:

1. Reviewing Medical Charts

• Read inpatient hospital records to understand what happened clinically during a patient’s stay.
• Determine whether the diagnosis and procedure codes assigned match the clinical story.

2. Verifying Coding Accuracy

• Validate ICD-10-CM diagnosis codes
• Validate ICD-10-PCS procedure codes
• Confirm sequencing (the order of codes)
• Ensure correct DRG assignment
• Check Present-on-Admission (POA) indicators
• Validate severity levels like: SOI (Severity of Illness) ROM (Risk of Mortality) HCCs (Hierarchical Condition Categories) CMI (Case Mix Index impact)

3. Ensuring Compliance

• Ensure coding follows: CMS (Centers for Medicare & Medicaid Services) guidelines Official Coding Guidelines National Coverage Determinations (NCDs) Local Coverage Determinations (LCDs) MCG, InterQual, and payer policies Best practices set by AHIMA and ACDIS

4. Clinical Documentation Integrity (CDI) Support

• Identify incomplete or unclear documentation
• Create and send physician queries when documentation needs clarification
• Support clients’ CDI programs by reviewing query quality and accuracy

5. Quality Assurance & Reporting

• Maintain accuracy and productivity benchmarks
• Provide audit results and feedback to internal teams and external clients
• Assist with developing training materials and guiding new hires

6. Data, Technology & Security

• Use multiple EMRs and coding software systems
• Maintain password/access integrity
• Ensure strict compliance with HIPAA and PHI handling
• Participate in required training and meetings

Required Knowledge, Skills & Abilities

These are essential, non-negotiable skills for qualified candidates:

Technical Skills

• Expert-level inpatient ICD-10-CM/PCS coding knowledge
• Strong understanding of DRG payment systems
• Ability to interpret clinical documentation
• Familiarity with clinical criteria (MCG, InterQual)
• Ability to analyze data and identify trends

Certifications (Typically Required or Highly Preferred)

Candidates should hold a CCS or RHIT at a minimum, any other certifications are a plus:

• CCS (Certified Coding Specialist) — most common and preferred
• RHIT
• CDIP, CCDS, or RHIA is a plus (CDI-related credentials, preferred but not required for all roles, must be held in addition to CCS)

Experience

• Typically 3+ years of inpatient coding experience
• DRG auditing experience preferred
• Experience with physician queries and CDI best practices
• Familiarity with hospital EMRs (Epic, Cerner, Meditech, etc.)

Ideal Candidate Traits

• Strong critical thinking and analytical skills
• Ability to read and interpret complex medical information
• High attention to detail and accuracy
• Excellent communication (written and verbal)
• Ability to work independently and meet deadlines
• Professional, ethical, and reliable

Why This Job Matters

Accurate DRG and coding validation ensure:

• Hospitals receive correct reimbursement
• Patient records are clinically accurate
• Compliance with federal and payer regulations
• Reduced risk of audits or financial penalties

This role is essential for revenue cycle integrity and overall financial health of healthcare organizations.

Additional Responsibilities (As Needed)

• Support special projects
• Assist with workflow improvement
• Provide training or mentoring
• Collaborate with auditors, coders, CDI staff, and leadership