RN Inpatient DRG Validation Specialist

RN Inpatient DRG Validation Specialist

Remote, Nationwide

Our client is a rapidly growing healthcare technology organization modernizing how health plans identify payment inaccuracies and evaluate complex inpatient claims. As the organization expands its Payment Integrity capabilities, it is building a team of experienced nurse auditors who can pair strong clinical judgment with deep DRG expertise. This role offers an RN the chance to apply clinical expertise beyond conventional claims auditing, help modernize review methodologies, and support technology-driven approaches that strengthen payment integrity.

This Role Offers:

• Competitive base salary, plus an annual bonus opportunity.
• Join a growing Payment Integrity organization with significant investment in team expansion.
• Collaborate with operational and technology teams as clinical insight helps shape smarter audit processes and technology-enabled review capabilities.
• Opportunity for visibility and professional growth within a fast-moving healthcare technology environment.
• Comprehensive benefits, including medical, dental, vision, 401(k), and flexible paid time off.

Focus:

• Review inpatient claims and medical records to determine whether diagnoses, procedures, supporting documentation, and other clinical factors substantiate the assigned DRG.
• Evaluate principal and secondary diagnoses, relevant procedures, severity indicators, sequencing, and discharge information for appropriate inpatient reimbursement.
• Use clinical judgment to recognize unsupported conditions, documentation discrepancies, and potential issues affecting DRG assignment or payment accuracy.
• Translate clinical analysis into succinct audit decisions with a strong rationale supporting each determination.
• Participate in prepayment and postpayment review workflows as assigned while maintaining accuracy, consistency, and appropriate turnaround times.
• Stay current on inpatient reimbursement practices, ICD-10-CM and ICD-10-PCS concepts, DRG methodologies, payer requirements, and relevant regulatory guidance.
• Work with Payment Integrity, operations, and technology partners to strengthen review methods, quality standards, and clinical audit workflows.
• Navigate clinical audit tools, electronic health records, and claims information while maintaining appropriate privacy and compliance standards.

Skill Set:

• Active Registered Nurse (RN) license is required. This position is specifically seeking RN candidates.
• 3 or more years of relevant experience spanning inpatient DRG validation, clinical claims auditing, CDI review, inpatient clinical review, or comparable Payment Integrity work.
• Demonstrated hands-on experience performing clinical DRG validation or inpatient DRG audits, rather than experience limited to coding or administrative functions.
• Strong clinical judgment when evaluating medical records, diagnoses, procedures, documentation, and the clinical validity of DRG assignments.
• Knowledge of inpatient reimbursement and ICD-10-CM and ICD-10-PCS concepts, with familiarity across common DRG methodologies.
• Experience within payer, Payment Integrity, healthcare audit, consulting, or similar environments is highly valued, with exposure to both prepayment and postpayment review preferred.
• Skilled at articulating sound clinical reasoning, supporting review conclusions, and presenting findings with clarity and confidence.
• Comfortable working independently in a remote setting and using EHRs, claims systems, and clinical audit platforms. Coding, CDI, or auditing certifications are beneficial but are not required.

About Blue Signal:

Blue Signal is an award-winning, executive search firm specializing in various specialties. Our recruiters have a proven track record of placing top-tier talent across industry verticals, with deep expertise in numerous professional services. Learn more at bit.ly/46Gs4yS