DRG Dispute Reviewer

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

The DRG Dispute Reviewer is responsible for evaluating provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. This role requires advanced knowledge of MS-DRG and APR-DRG methodologies, clinical validation, coding guidelines, and payer policies. Using clinical and coding expertise, the reviewer independently assesses documentation to ensure audit decisions are accurate, defensible, and compliant. This position plays a vital role in supporting regulatory compliance, identifying and recovering over payments, and promoting proper documentation and reimbursement practices across healthcare systems.

• Dispute Review:
  Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.
• Medical Record Analysis:
  Review inpatient medical records, UB-04s, and documentation to ensure correct DRG assignment and adherence to coding, billing, and payment guidelines.
• DRG Validation:
  Apply clinical validation and coding principles to support or overturn DRG audit findings using MS-DRG and APR-DRG grouping logic.
• Written Justification:
  Prepare clear, concise, and evidence-based rationales to support determinations for clients, providers, or payers.
• Coding Expertise:
  Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.
• Clinical Judgment:
  Use clinical acumen to assess medical necessity, documentation sufficiency, and code assignment accuracy.
• Collaboration:
  
  Work closely with audit leads and team members to ensure consistency and quality in dispute resolutions.
• Quality & Productivity:
  Meet performance standards for accuracy, timeliness, and productivity in dispute review and audit completion.
• Compliance:
  Adhere to HIPAA guidelines, industry best practices, and AHIMA’s Standards of Ethical Coding.
• Client Communication:
  Participate in client meetings, including presenting audit results when required.
• Tool Utilization:
  Use proprietary audit platforms, encoders, and medical record systems efficiently and effectively.
• Other Duties:
  Perform additional tasks as assigned to support audit operations and client needs.

• An associate or bachelor’s degree in nursing (active/unrestricted license); or in health information management is required.

Work experience may be considered in lieu of formal education at leadership discretion.

• RHIA – Registered Health Information Administrator
• RHIT – Registered Health Information Technician
• CCS – Certified Coding Specialist
• CIC – Certified Inpatient Coder
• CDIP or CCDS – Clinical Documentation Improvement certification

• Minimum 3 years of inpatient hospital coding (IPPS reimbursement)
• Minimum 4 years DRG validation (clinical and coding)
• Experience in DRG dispute reviews, clinical validation, and recovery audits strongly preferred
• Prior experience in inpatient clinical documentation integrity (CDI) is a plus

• Expert-level knowledge of ICD-10-CM/PCS coding systems,…