Overview

The DRG Validation Auditor plays a critical role on the DRG Validation Team, ensuring the accuracy of medical coding and appropriate reimbursement for services billed under Commercial and Government health plans.

This position involves analyzing medical records, validating DRG assignments, and identifying potential overpayments or underpayments across various healthcare settings, including acute care hospitals, long-term acute care facilities, rehabilitation centers, and skilled nursing facilities.

Auditors receive comprehensive training in medical record review, coding guidelines, and client-specific documentation formats. Ongoing education is also provided to ensure alignment with evolving coding standards, reimbursement methodologies, and audit processes.

Key Responsibilities

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  Review inpatient medical records to validate assignment and sequencing of ICD-10-CM/PCS diagnosis and procedure codes, discharge status, Hospital-Acquired Conditions (HACs), Present on Admission (POA) indicators, and DRG assignments.

  
  


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  Prepare clear, well-documented DRG Review Results letters, providing detailed rationale and appropriate references.

  
  


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  Refer complex or ambiguous cases to a Clinical Nurse Auditor or Physician Advisor when necessary.

  
  


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  Apply all relevant coding standards, payer guidelines, and reference materials during reviews.

  
  


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  Collaborate with the Edit Development Team to provide insights on claim selection criteria.

  
  


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  Verify and reconcile data received from clients, addressing discrepancies proactively.

  
  


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  Communicate professionally with healthcare providers during onsite or remote reviews.

  
  


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  Maintain compliance with organizational procedures, including documentation, timekeeping, and travel reporting.

  
  


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  Inform Team Leads promptly regarding schedule changes, technical issues, or performance barriers.

  
  


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  Meet or exceed established standards for audit quality, accuracy, and productivity.

  
  


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  Perform additional duties as assigned.

  
  

Required Qualifications

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  Current AHIMA credential (RHIT, RHIA, or CCS) — CCS preferred.

  
  


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  Minimum of 2–3 years of inpatient coding experience.

  
  


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  Strong command of ICD-10-CM/PCS and DRG reimbursement methodologies.

  
  


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  Skilled in MS-DRG and APR-DRG systems.

  
  


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  Demonstrated ability to provide clinical validation and perform detailed data analysis.

  
  


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  Proficient in Microsoft Office Suite (Word, Excel, Outlook) and Windows OS.

  
  


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  Strong written communication skills — able to produce clear, structured, and grammatically sound narratives.

  
  


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  Organized, detail-oriented, and capable of managing multiple priorities in a fast-paced environment.

  
  


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  Experience training or mentoring junior coders is highly desirable.

  
  


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  Self-directed with a commitment to continuous learning and professional growth.

  
  


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  Must be willing to work in a hybrid setup based in Taguig and travel occasionally for training or onsite reviews.

  
  

Preferred Atributes

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  Strong analytical thinking and problem-solving skills.

  
  


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  Professional communication style with a high level of integrity and accountability.

  
  


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  Adaptable and receptive to feedback and process improvements.