Manager, Payer Clinical Services (DRG)

Role and Responsibilities

Oversee clinical/coding DRG audits, including MS-DRG, APR-DRG, readmission, and short-stay reviews, to ensure accuracy and compliance with internal policies and industry-standard guidelines.
Identify gaps and improvement opportunities and provide staff education to enhance audit quality and drive revenue performance.
Apply appropriate industry-standard coding guidelines, payer policies, and medical journal references relevant to audit review.
Maintain strong client relationships through accurate clinical and coding audits, continued understanding of client issues and needs, and compliance with payer policies, procedures, guidelines, and continuum-of-care requirements.
Identify client trends related to coding denials and report findings to the clinical team and clients, ensuring client issues are thoroughly acknowledged.
Oversee current staff and new-hire training related to technology, regulatory changes, and operational processes to support efficiency, client satisfaction, and high-quality results.
Participate in the development of education tools for staff and communicate expectations clearly to each team member.
Ensure clients receive detailed historical and current trend reports and verbally communicate findings to clients, coding teams, and nursing teams as appropriate.
Coach, develop, and mentor clinical staff to achieve quality performance by sharing knowledge and practicing servant leadership principles.
Continue developing personal management skills necessary to lead teams and handle unique operational challenges.
Organize training for new and existing team members to ensure each receives the information and tools needed to be successful.
Independently prepare, deliver, and assign client communications to support audit findings.
Maintain required certifications and continuing education requirements.

Qualifications

• Administration, or a related field; equivalent work experience in a similar position may be considered.
• Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Registered Nurse credential preferred.
• Active coding certification, such as CCS, CPC, or CIC.
• Extensive experience in DRG coding validation and/or auditing.
• Experience training others.
• Experience leading or managing a team.

Preferred Skills

• DRG validation experience, including MS-DRG.
• DRG validation experience, including APR-DRG.
• Readmission audits.
• Short-stay audits.
• Policy development.
• Quality assurance experience.

MENTAL AND PHYSICAL DEMANDS

• This position will be exposed mainly to an indoor office environment and will be expected to work in or around computers and printers.
• The nature of the work is sedentary, and the employee will be sitting most of the time.
• Essential physical functions of the job include typing and the repetitive motion to utilize computer software and hardware continuously throughout the day.
• Essential mental functions of this position include concentrating on analytical tasks, reading information, and verbal/written communication to others continuously throughout the day.
 

RELATED DUTIES AS ASSIGNED

• This job description documents the general nature and level of work but is not intended to be a comprehensive list of activities, duties, or responsibilities required for this position. Consequently, employees may be asked to perform other duties as required.
• Employees may also be asked to complete certain compliance requirements set forth by our Business Partners in the performance of their jobs including but not limited to requests for background and drug screenings and disclosures of personal health information or personally identifiable information. Exemptions as provided under the ADA and TITLE VII of the Civil Rights Act will be observed and followed.
• Reasonable accommodations may be made to enable individuals with disabilities to perform the functions outlined above.