DRG Manager
Core
Leads the development and management of clinical payment integrity solutions, focusing on MS-DRG and APR-DRG validation to identify payment issues and support healthcare cost recovery.
Role type
Senior Manager, Clinical Payment Integrity & DRG Validation
Builds
Scalable clinical claims review solutions and payment integrity programs
Domain
Healthcare / Reimbursement & Payment Integrity
Required skills
MS-DRG validation, APR-DRG validation, claims auditing, healthcare billing and coding, Medicare and commercial coding rules, prospective payment systems, readmission reviews, place-of-service reviews, Milliman and InterQual guidelines, team management, data analytics
Preferred skills
None explicitly stated
Technologies
None explicitly stated
Responsibilities
Lead development and review of clinical payment solutions; oversee end-to-end clinical claims review process; collaborate with cross-functional teams to implement DRG concepts; monitor regulatory changes and update review methodologies; lead and develop the DRG team; assign workloads and ensure timely delivery; monitor team performance and quality; analyze claims data to identify trends and root causes; design programs to correct aberrant claims; provide evidence and rationale for review decisions; manage project timelines and client-facing activities.
Seniority
Senior, hands-on IC with team leadership