Integrity DRG Coding & Clinical Validation Analyst I​/Ii​/Iii; RHIA, RHIT, CCS, or CIC Ce

Payment Integrity DRG Coding & Clinical Validation Analyst I/II/III (RHIA, RHIT, CCS, or CIC Certification Required)

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The Payment Integrity DRG Coding & Clinical Validation Analyst position requires extensive experience in acute facility-based clinical documentation and inpatient coding, with a strong understanding of MS‑DRG and APR‑DRG payment systems. Responsibilities include reviewing medical records for accurate provider documentation to support principal diagnoses, comorbidities, complications, secondary diagnoses, surgical procedures, and POA indicators. The analyst validates coding and DRG assignment accuracy, ensuring physician documentation aligns with hospital coded data and adheres to CMS and other regulatory standards.

• Analyzes and audits acute inpatient claims, integrating medical chart coding principles and clinical guidelines.
• Applies advanced ICD‑10 coding expertise and industry knowledge to substantiate conclusions.
• Adheres to official coding guidelines, coding clinic determinations, and CMS regulatory mandates.
• Establishes national and best‑practice benchmarks, measuring performance against them.
• Ensures accurate payment by independently using DRG grouper, encoder, and claims processing platform.
• Manages case volumes and review/audit schedules, prioritizing case loads per management assignment.
• Demonstrates integrity by supporting the Lifetime Healthcare Companies’ mission, values, and Corporate Code of Conduct.
• Maintains respect for member privacy per corporate privacy policies.
• Exhibits reliable attendance as required.
• Performs other functions as assigned by management.

• Performs complex audits or projects with minimal direction or oversight.
• Acts as an expert in medical coding and record review, overseeing complex assignments and challenging customers.
• Supports leadership in projects related to divisional/departmental strategies and initiatives.
• Participates and represents in audits, payment methodologies, and contractual agreements with cross‑functional teams or business partners.
• Serves as a mentor to new hires.
• Engages on department committees, both internal and external.

• Provides expertise in developing audit data criteria.
• Acts as a lead, offering training, guidance, complex performance analysis, and coaching to team members on continuous quality improvement.
• Resolves escalations in partnership with Payment Integrity staff.
• Provides backup support for management as necessary.

• Associate or bachelor’s degree in Health Information Management (RHIA or RHIT) or Nursing.
• Three (3) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Three (3) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and comprehensive knowledge of medical claims billing/payment systems and coding terminology.
• Maintained coding certification (RHIA, RHIT, Inpatient Coding Credential – CCS or CIC) as a condition of employment.
• Intermediate analytical and problem‑solving skills with awareness of business analysis trends.
• Intermediate knowledge of PC, software, auditing tools, and claims processing systems.

• Five (5) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Five (5) years of experience with ICD‑10CM, MS‑DRG, and APR‑DRG, and advanced knowledge of medical claims billing/payment systems.
• Demonstrated ability across multiple skills, products, processes, and systems.
• Demonstrated leadership of initiatives with occasional guidance from management.
• Advanced analytical, problem‑solving, and judgment skills.
• Advanced knowledge of PC, software, auditing tools, and claims processing systems.

• Eight (8) years of claims auditing, quality assurance, or recovery auditing experience in DRG coding for hospital or acute facility settings.
• Eight (8) years of experience with ICD‑10CM, MS‑DRG, and…