DRG QA/Training Manager

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

📋 Description

• Lead the DRG Quality Assurance/Trainer team by establishing objectives and organizing audit and training initiatives.

• Provide mentorship, guidance, development plans, and performance evaluations for QA/Trainer personnel.

• Manage the Quality Assurance audit program for both new and current DRG Reviewers.

• Analyze audit results, calibrate audit criteria, discern trends and root causes, and execute corrective measures.

• Propel continuous enhancement in audit accuracy, workflow effectiveness, and reviewer performance.

• Design and conduct onboarding training focused on DRG methodologies, clinical validation, and proprietary tools.

• Supervise ongoing training efforts and maintain training materials and resources.

• Formulate QA policies, processes, and training standards.

• Keep records of audits, feedback, and training documentation.

• Report on quality metrics, audit results, and training effectiveness.

• Collaborate with DRG Managers, the DRG Clinical Educator, and teams in operations, product, data analytics, and technology.

• Act as a knowledgeable resource on intricate cases and procedures.

• Assist with research, special projects, and ad hoc claims reviews.

⛳️ Requirements

• A bachelor’s degree in nursing (with an active/unrestricted license), health information management, or health administration is mandatory.

• Relevant work experience may be accepted in place of formal education at the discretion of leadership.

• A minimum of one certification is required: RHIA, RHIT, CCDS, CDIP, CCS, or CIC.

• At least 5 years of experience in healthcare billing and coding.

• 3 or more years of experience in inpatient claims auditing, quality assurance, recovery auditing, and/or inpatient Clinical Documentation Integrity.

• Previous supervisory experience is essential.

• Experience in production and team leadership.

• Proven experience in training clinical or coding personnel.

• Familiarity with readmission reviews.

• Demonstrated experience in conveying DRG audit process knowledge to sales, marketing, and development teams.

• Proficient understanding of DRG methodologies and classification systems, including MS-DRG, APR-DRG, and AP-DRG.

• Extensive knowledge of ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.

• Expertise in DRG validation, clinical criteria, and documentation prerequisites.

• Comprehensive understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.

• Familiarity with Milliman and InterQual guidelines.

• Strong data analysis capabilities and critical judgment skills.

• Ability to provide clear, actionable feedback and coaching.

• Experience utilizing multiple monitors and remote work settings.

• Proficient in Windows, Microsoft Suite, Teams, Excel, PowerPoint, and Word.

🏝️ Benefits

• Work remotely from anywhere in the US; a digital-first workplace.

• Comprehensive Medical/Dental/Vision benefits.

• Flexible Spending Account (FSA) and Health Savings Account (HSA).

• Tuition reimbursement program.

• 401(k) plan with company matching.

• Additional health and wellness benefits and perks.

• A flexible and trusting work environment.