DRG Manager

About the Role:

The DRG Manager is responsible for the development and management of our clinical solutions, including MS and APR-DRG validation. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Key responsibilities include inventory and team management, implementation support, client support, research, and management.  This role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of our clinical solutions and ensure optimal team performance.

Who You Are:

• Enhance and Review Clinical Solutions: Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.


• Collaborative Development: Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.


• Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.


• Team Leadership: Lead the DRG team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth of DRG staff.


• Claims Review Management: Oversee the entire process of clinical claims review, understanding various client configurations and workflows.


• Operational Oversight: Manage scheduling, reporting to management, issue resolution, and execution of plans.


• Work Coordination: Assign and prioritize work, set goals, and coordinate daily activities of the team. Provide regular updates and communication through one-on-one and team meetings.


• Performance Monitoring: Monitor individual and team results to ensure timely completion of work in accordance with department standards and medical policy guidelines.


• Analytical Problem-Solving: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.


• Policy and Process Development: Develop departmental policies, processes, and training standards.


• Support and Evidence: Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.


• Performance Reporting: Provide reports on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory on a predetermined schedule.


• Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.


• Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.


• Program Deployment: Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.


• Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.


• Other Duties: Perform other duties as assigned.

What You Bring to the Table:

Skills, Knowledge, Education, and Experience

• Bachelor’s degree (health administration, business, nursing)


• Equivalent experience of 5+ years in healthcare billing and coding


• Equivalent experience of 2+ years in claims auditing and recovery auditing


• Preferred coding certification and nursing license

 Experience:

• Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams


• Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG


• Preferable experience with outpatient payment systems such as APCs and EAPGs


• Demonstrated curiosity and mastery in understanding the root cause of events and behaviors


• Strong experience in data utilization and insights


• Experience independently structuring and executing complex analyses


• Familiarity with Milliman and InterQual guidelines


• Expertise in DRG validation


• Experience in production and team management


• Experience with Readmission reviews


• Ability to work efficiently and effectively with minimal supervision


• High standards of quality and attention to detail


• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems


• Superior knowledge of healthcare coding, billing, and reimbursement


• Expert knowledge of clinical criteria documentation requirements


• Subject matter expertise in DRG validation

Computer Equipment and Software:

• Experience working with multiple monitors


• Proven success in a remote working environment


• Proficient in Windows office systems, including the full Microsoft Suite and Teams


• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)


• Experience with various software applications and collaboration with development teams


• Familiarity with multiple encoder/grouper applications

Physical Demands:

• Ability to sit or stand for long periods, with occasional stooping and reaching


• May require lifting up to 25 pounds


• Requires a normal range of vision and hearing, with or without accommodations


• Position is not substantially exposed to adverse environmental conditions