Senior Manager - DRG Concept Development Analyst

Responsibilities

• Collaborate with Payment Integrity Audit program leaders, DRG audit professionals and Data & Analytic team members to research, develop and implement inpatient DRG audit selection criteria.
• Analyze performance metrics and results to ensure alignment with team goals.
• Develop and adjust selection criteria based on specific client requirements.
• Monthly claim screening and selection.
• Verify selections output to ensure selection rules are functioning as intended.
• Review appeals/disputes to identify areas for improvement.
• Create education and training documents and conduct handoff meetings with the Audit teams to ensure understanding of new audit concepts.
• Ensure the clinical team is calibrated with client policies and internal concepts.
• Utilize Audit Outcome trend reports to monitor and fine-tune existing queries.

Qualifications

• 10+ years of inpatient coding or auditing experience with a mastery level expertise in both MS DRG and APR-DRG methodology.
• Experience developing audit selection criteria to identify MS DRG & APR-DRG coding errors and overpayments preferred.
• Experience working with large data sets.
• Adept at identifying meaningful patterns, trends and root causes from data.
• Advanced analytical and problem-solving skills.
• Industry knowledge specific to MS DRG & APR-DRG reimbursement, provider contracts, payer policies, and audit regulations.
• Excellent oral and written communication skills.

Education and Required Certification

• Bachelor’s degree in health information management, Healthcare Informatics or Health Care Administration.
• Active AHIMA certification - RHIA, RHIT or CCS.

Work Experience Requirements

• Experience with encoder tools (3M, Trubridge).
• Proficient in Microsoft Excel including advanced functions and pivot tables and Power Point.
• Experience with AI tools preferred.