Position Name- Specialist DRG (DRG Validation)

Experience - 3+ years of overall experience with 1+ years of experience in Quality Analysis within the healthcare / RCM domain.

Position Summary-

Performs documentation and coding audits for all acute inpatient services for clients. Identifies coding errors, compliance, and educational opportunities, and optimizes reimbursement by ensuring that the diagnosis/procedure codes and supporting documentation accurately support the services rendered and comply with ethical coding standards/guidelines and regulatory requirements. Performs independent reviews, interprets medical records, and applies in-depth knowledge of coding principles to determine billing/coding/documentation issues and quality concerns.

Demonstrates high level of expertise in researching requirements necessary to make compliant recommendations.

Job Responsibilities -

- Conducts DRG (ex. MS, APR, Tricare) coding and clinical reviews to verify the accuracy of coding, DRG assignment and clinical indicators in accordance with coding and documentation guidelines. Ensures that the assigned DRG reflects the severity of the patient’s condition and the resources used during their hospital stay.
- Assesses whether the clinical documentation supports the coded diagnoses and procedures. Verifies that the medical record adequately justifies the assigned DRG.
- Combines medical record coding guidelines, clinical principles, and industry trends to explain any recommended changes needed by coders. Works closely with CDI (Clinical Documentation Integrity) specialists to determine if there are documentation and/or query opportunities.
- Maintains productivity and quality goals as set by audit leaders.
- Writes explicit,



accurate and concise recommendations in support of findings while providing feedback and education to acute inpatient coders, referencing current ICD-10-CM/PCS Official Coding Guidelines and AHA Coding Clinics.
- Ensures acute inpatient coding audits are completed accurately and timely by meeting client turn around and audit quality expectations.
- Responsible for maintaining current certification(s), CEU’s, and up-to-date knowledge of coding guidelines.
- Completes required education through internal application, compliance training and other mandatory educational requirements.
- Use proprietary systems and encoder tools efficiently and accurately to make audit determinations, generate audit recommendations through workflow processes accurately.
- Identifies any potential overpayments or underpayments by analyzing claims, on a 30-day lookback, to identify any discrepancies between billed DRGs and the actual services provided.
- Leverages ICD-10 coding expertise, clinical guidelines, and proprietary tools to substantiate conclusions.
- Continues to stay informed about changes in acute inpatient coding regulations and reimbursement policies.
- Identifies potential opportunities, outside of the normal scope, where there may be additional recoveries or compliance concerns.



Shares and assists in development of concepts and or process improvement, tools, etc.
- This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job related duties as required by their supervisor, subject to reasonable accommodation.

Educational Qualifications

- Graduate in any discipline (B.Sc./M.Sc. Nursing, B. Pharm, M. Pharm, or Life Sciences education is preferred)
- Certification in Medical Billing and Coding (CPC, CCS, or equivalent) preferred.
- 3+ years of overall experience with 1+ years of experience in Quality Analysis within the healthcare / RCM domain.
- Strong understanding of end-to-end RCM processes including charge entry, payment posting, denial management, and AR follow-up.
- Knowledge of HIPAA and healthcare compliance standards.
- Proficiency in using billing software (e.g., Epic, Athena, Kareo) and QA tools.

About Us Ensemble Health Partners

- The single solution for a frictionless revenue cycle. We were founded in 2014 with the purpose of redefining the possible in healthcare by empowering people to be the difference . Since then, we’ve grown to support revenue cycle excellence for hundreds of hospitals.

From talent to technology , we at Ensemble provide a single-solution healthcare to industry leaders, enabling them to reach peak RCM performance persistently. Ensemble Health Partners, India — the company’s Global Capability Center with its flagship facility in Hyderabad serves as a hub for certified professionals managing revenue cycle functions for Ensemble.

📌 Specialist DRG (DRG Validation) (Hyderabad)
🏢 ensemble global
📍 Hyderabad