DRG Manager
New
M
MachinifyHealthcare
Remote - USFull-TimeManager
Salary125,000 - 140,000 USD per year
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Job Details
- Experience
- 5+ years in healthcare billing and coding, 3+ years in claims auditing and recovery auditing
- Required Skills
- Product ManagementTeam management
Requirements
- Bachelor’s degree (health administration, business, nursing)
- 5+ years in healthcare billing and coding (equivalent experience)
- 3+ years in claims auditing and recovery auditing (equivalent 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, 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
Responsibilities
- 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.
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