Senior Claims Auditor - DRG

About this role

Opportunity Overview:

We are seeking a Senior Inpatient Auditor to join our dynamic Payment Integrity team. This critical role involves conducting comprehensive MS-DRG and APR-DRG coding reviews to ensure the accuracy of claims and maximize overpayment identification. If you possess a CCS credential, superior knowledge of ICD-10-CM/PCS coding guidelines, and a passion for deep analytical work, you will be instrumental in supporting Cohere Health’s commitment to accurate reimbursement solutions. This opportunity requires a self-motivated individual who thrives on precision, compliance, and continuous learning in a high-growth environment.

What you’ll do:

• Conduct comprehensive MS-DRG and APR-DRG coding reviews to ensure accuracy in DRG assignment and reimbursement.

• Apply expert knowledge of coding guidelines and utilize industry-leading tools to maximize overpayment identifications.

• Craft clear, concise, and well-supported audit findings, backed by AHA Coding Clinic Guidelines and ICD-10-CM/PCS regulations.

• Utilize advanced DRG encoder tools to drive efficiency and accuracy in audits.

• Meet or exceed company quality and productivity standards, including strong uphold rates for appeals.

• Stay ahead of industry trends, coding updates, and compliance regulations to maintain expert-level knowledge.

• Adhere to HIPAA and company policies and procedures to ensure data security and regulatory compliance.

• Maintain and apply superior knowledge of changes and updates to coding guidelines, reimbursement trends, and health payment policy language.

What you’ll need:

• 6+ years experience of performing MS-DRG and ARP-DRG reviews for a Payment Integrity vendor or Payer required.

• An active certified coder credential (e.g., CIC, CPC, CCS, RHIA, or RHIT) required.

• CCS (Certified Coding Specialist) credential highly preferred.

• Requires advanced expertise in ICD-10-CM/PCS coding and the ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding.

• Prepares clear, concise, and well-supported audit findings, referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines, ensuring recommendations reflect professional expertise.

• Self-motivated and able to work independently in a remote environment while maintaining high performance.

• Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously.

• Passion for DRG auditing and a commitment to teamwork, collaboration, and continuous learning.

• RHIA, or RHIT credential, Associate's Degree in Health Information Management, Nursing, or related field preferred.

• Inpatient audits for case rate and per diem preferred.

• Experience working in a start-up or high-growth company environment, demonstrating agility and adaptability.

• Familiarity with working with a diverse, global team of talent.

• Excellent computer skills and familiarity with a Mac.

Pay & Perks:

💻 Fully remote opportunity with about 5% travel

🩺 Medical, dental, vision, life, disability insurance, and Employee Assistance Program

📈 401K retirement plan with company match; flexible spending and health savings account

🏝️ Flex Time Off + company holidays

👶 Up to 14 weeks of paid parental leave

🐶 Pet insurance

The salary range for this position is $85,000 to $100,000 annually; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment. This role is not eligible for hire in: AK, CA, CO, HI, NY, or WA.

Interview Process*:

• Connect with Talent Acquisition for a Preliminary Phone Screening

• Meet your Hiring Manager!

• Case Study

• Interview with Subject Matter Expert

• Behavioral Interview

*Subject to change

About Cohere Health:

Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members.

With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with…