The DRG Coder is responsible for reviewing inpatient medical records and accurately assigning diagnosis and procedure codes using ICD-10-CM and ICD-10-PCS to determine the appropriate Diagnosis-Related Group (DRG) assignment.
This role ensures coding accuracy, reimbursement integrity, and compliance with federal and state regulations, payer guidelines, and internal policies. In an Independent Practice Association (IPA) and Management Services Organization (MSO) environment, the DRG Coder partners with utilization management, care management, finance, and provider network teams to support accurate payment, risk adjustment, quality reporting, and medical expense analysis.What You'll Do
Review inpatient hospital records and assign accurate diagnosis and procedure codes
Determine the appropriate MS-DRG or APR-DRG assignment based on coding and clinical documentation
Conduct coding validation and auditing to ensure compliance with payer and regulatory requirements
Identify documentation gaps and communicate opportunities to providers, hospitals, and Clinical Documentation Improvement (CDI) teams
Analyze denials and underpayments related to coding and DRG assignment
Support retrospective and concurrent reviews of high-cost admissions and outlier cases
Collaborate with utilization management, case management, finance, and contracting teams to optimize reimbursement and cost containment
Assist with internal and external audits, including RAC, Medicare Advantage, Medicaid, and commercial payer reviews
Provide education and mentoring to coding staff and other stakeholders
Monitor changes in coding guidelines, reimbursement methodologies, and regulatory requirements
Prepare reports and summaries related to coding accuracy, financial impact, and audit findings
Maintain confidentiality and compliance with HIPAA and company policies
Other duties as assigned
Qualifications
Associate’s degree in Health Information Management, Nursing, or related field
Have at least 5 years of inpatient coding experience
Have at least 2 years of advanced DRG validation, auditing, or hospital reimbursement experience
Certifications Oneor more of the following required: • CCS, RHIA, or RHIT from American Health Information Management Association • CIC from AAPC
Have advanced knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG, and APR-DRG methodologies
Proficiency in coding software, electronic medical records, and Microsoft Office applications
You're great for the role if:
Experience working with Medicare Advantage, Medicaid, and commercial health plans
Experience in a delegated IPA, MSO, or managed care environment
Have a strong understanding of Medicare reimbursement and payer audit processes
Ability to interpret complex clinical documentation
Knowledge of utilization management, case management, and managed care operations
Strong analytical, organizational, and problem-solving skills
Ability to work independently and manage multiple priorities
Excellent written and verbal communication skills.
Environmental Job Requirementsand Working Conditions
This position is remotely based in the U.S. The home office is located at 600 City Parkway West 10th Floor, Orange, CA 92868.
This role is required to attend occasional in-person meetings with internal departments and external providers/hospitals, training, or audit purposes.
The national target pay range for this role is between $28.00 - $32.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
Astrana Healthis proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
Originally posted on Himalayas