DRG Manager

The company is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, the company brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Opportunity

At the company, we’re constantly reimagining what’s possible in our industry—creating disruptively simple, powerfully clear ways to maximize our clients’ financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions Team, you will, as the DRG Manager, be 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.

What you’ll do

• 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'll bring

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

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

• Equivalent experience of 3+ years in claims auditing and recovery auditing

• 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, and 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 APR-DRG validation, Readmissions, and Place of Service

What we offer

• Work from anywhere in the US! The company is digital-first.

• Top Medical/Dental/Vision offerings

• FSA/HSA

• Tuition reimbursement

• Competitive salary, 401(k) with company match

• Unlimited PTO

• Additional health and wellness benefits and perks

• Flexible and trusting environment where you’ll feel empowered to do your best work

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc. We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range. Salary is one component of the total compensation package, which includes meaningful equity, excellent healthcare, flexible time off, and other benefits and perks.

Pay range : $125,000-$140,000 USD, plus annual bonus.

Equal Employment Opportunity at the company

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. The company is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at:  [link for members]