Director, Pre-bill DRG Validation Program

This is a fully remote position, open to applicants in United States.

📋 Description

• Take ownership of the complete design, implementation, and ongoing enhancement of the pre-bill DRG validation program for designated client engagements.

• Set program objectives, key performance indicators, and service-level commitments; provide performance reports to executive leadership and clients.

• Create and uphold review methodologies, case selection criteria, and prioritization standards.

• Discover opportunities to broaden service offerings and assist in business development by providing subject-matter expertise, proposal contributions, and client presentations.

• Act as the senior clinical and coding authority for DRG validation, clinical validation, and query practices.

• Ensure that reviews adhere to ICD-10-CM/PCS Official Guidelines, AHA Coding Clinic, CMS regulations, ACDIS/AHIMA query guidelines, and payer policies.

• Address escalated and complex cases, including disputes over clinical validation, conflicting documentation, and significant DRG shifts.

• Maintain a quality assurance program with targets for inter-rater reliability, second-level reviews, and corrective actions.

• Recruit, onboard, develop, and retain clinical validators, DRG auditors, and CDI professionals.

• Establish productivity and quality expectations; conduct evaluations; oversee coaching, development plans, and corrective actions.

• Design and deliver training on regulatory changes, coding updates, and clinical validation topics.

• Manage staffing models, capacity planning, and workload allocation.

• Serve as the executive point of contact for client HIM, CDI, Compliance, and Revenue Cycle leadership.

• Facilitate client governance meetings, present outcomes and trend analyses, and offer recommendations for documentation and coding improvements.

• Resolve client escalations and oversee program modifications, scope changes, and issue remediation.

• Ensure adherence to HIPAA, OIG guidance, and CorroHealth policies; support audit processes.

• Collaborate with Analytics on dashboards and reporting related to DRG changes, financial impacts, query responses, denials, and reviewer performance.

• Work alongside Technology and Product teams on workflow tools, case routing, and automation initiatives.

• Oversee the program budget, labor costs, vendor relationships, and profitability targets.

⛳️ Requirements

• Registered Nurse (BSN or ADN with active licensure), Doctor of Medicine (MD/DO), Physician Assistant, Nurse Practitioner, or equivalent clinical credential from an accredited institution.

• A Bachelor's degree is mandatory.

• A Master's degree (MSN, MHA, MBA, or related) is preferred.

• CDI certification: CCDS (ACDIS) or CDIP (AHIMA) is required.

• Coding certification: CCS (AHIMA) is preferred.

• At least 10 years of practical experience in conducting and/or overseeing DRG validation reviews, including MS-DRG and APR-DRG methodologies, clinical validation, and pre-bill review workflows.

• A minimum of 5 years of experience in people management, leading clinical, coding, or CDI teams, including direct supervision of managers or team leads.

• Experience managing programs in a hospital, health system, payer, or healthcare consulting/outsourcing setting.

• A proven history of achieving measurable financial and quality outcomes through DRG validation or CDI programs.

• Expert knowledge of ICD-10-CM/PCS, MS-DRG and APR-DRG grouping logic, CC/MCC capture, SOI/ROM, and Coding Clinic guidance.

• In-depth understanding of compliant query practices, clinical validation standards, and payer denial and appeal procedures.

• Strong analytical abilities and the capacity to interpret program data and present insights to executive and clinical audiences.

• Executive presence, exceptional written and verbal communication skills, and the ability to influence physicians, HIM, and finance leaders.

• Proficiency with encoders, CDI platforms, and EHR systems such as 3M/Solventum, Epic, and Cerner/Oracle Health.

• Standard business hours with the flexibility to accommodate client time zones and deadlines.

• Preferred: experience in a multi-client outsourced services or consulting environment.

• Preferred: experience in building or scaling a pre-bill or concurrent review program from its inception.

• Preferred: experience with pediatric, academic medical center, or specialty inpatient populations.

• Preferred: familiarity with AI-assisted coding or CDI technologies and governance.

• Preferred: Six Sigma, Lean, or PMP certification.

🏝️ Benefits

• Annual performance-based bonus.

• Comprehensive medical, dental, and vision coverage.

• 401(k) with company match.

• Paid time off and holidays.

• Support for continuing education and certification maintenance.

• Remote work arrangement.

• Flexibility to accommodate client time zones and deadlines.