About this role
The Senior 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 Senior 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. 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