Senior Manager – APR DRG Concept Development Analyst

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

📋 Description

• Conduct research, analysis, and create new concepts and selection criteria to uncover overpayment opportunities in APR-DRG validation.

• Partner with audit and analytics teams to evaluate concepts both pre- and post-implementation.

• Track concept performance and pinpoint any performance-related issues.

• Utilize internal selection tools to formulate queries and concepts and assess their effectiveness.

• Present findings and insights to senior leadership.

• Modify selection criteria according to specific client needs.

• Execute monthly claim reviews and selections.

• Confirm selection outputs to guarantee that selection rules operate as intended.

• Analyze appeals and disputes to discover areas for enhancement.

• Develop educational and training materials and facilitate handoff meetings with audit teams.

• Ensure the clinical team is aligned with client policies and internal concepts.

• Leverage Audit Outcome trend reports to evaluate and optimize existing queries.

⛳️ Requirements

• Over 10 years of inpatient coding or auditing experience with expert-level proficiency in APR-DRG methodology.

• Preferred experience in creating audit selection criteria to detect APR-DRG coding mistakes and overpayments.

• Familiarity with handling large data sets.

• Ability to recognize significant patterns, trends, and root causes from data.

• Strong analytical and problem-solving capabilities.

• Knowledge of the industry with a focus on APR-DRG reimbursement, provider contracts, payer policies, and audit regulations.

• Exceptional oral and written communication skills.

• Bachelor's degree in health information management, healthcare informatics, or health care administration.

• Valid AHIMA certification: RHIA, RHIT, or CCS.

• Experience with encoder tools such as 3M and Trubridge.

• Proficiency in Microsoft Excel, including advanced functions and pivot tables, as well as PowerPoint.

• Experience with AI tools is a plus.

• Expert-level coding skills in ICD-10-CM and PCS.

• In-depth knowledge of ICD-10 Official Coding Guidelines and AHA Coding Clinic guidelines.

• Advanced comprehension of MS DRG and APR-DRG reimbursement methodologies.

• Up-to-date knowledge of relevant regulatory changes.

• A brief coding/auditing assessment may be part of the interview process.

🏝️ Benefits

• Options for healthcare, vision, dental, and 401k plans.

• A mentoring program providing guidance and coaching from seasoned professionals.

• Opportunities to collaborate with experienced, top-tier healthcare consultants.

• Professional and personal growth and development opportunities.

• Completely remote work from home.