Supervisor, Payment Integrity – Coding & Clinical

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

📋 Description

• Oversee and coordinate the daily operational activities of the Coding & Clinical Review team to guarantee the timely and precise completion of DRG audits, quality assurance, readmissions, appeals, and/or operational procedures.

• Assess and analyze team performance against set productivity, quality, and service level benchmarks; implement appropriate measures to address any identified gaps.

• Offer guidance and direction on coding, clinical validation, and audit decisions in line with ICD-10-CM/PCS guidelines, DRG methodologies, and relevant payer and regulatory policies.

• Examine and resolve intricate or escalated cases; escalate high-risk issues to management as necessary.

• Execute and endorse departmental policies, procedures, and program initiatives to ensure the consistent application of Payment Integrity strategies.

• Carry out quality assurance activities, including audits, calibration sessions, and inter-rater reliability assessments to maintain consistency and accuracy in determinations.

• Assist with the appeals process by evaluating clinical documentation, validating determinations, and overseeing response development.

• Analyze operational and audit data to recognize trends, variances, and opportunities for improvement; communicate findings to management.

• Ensure adherence to regulatory requirements, internal policies, payer guidelines, and AHIMA ethical standards; promote a culture of integrity and accountability.

• Collaborate with cross-functional teams (e.g., Medical Directors, Provider Relations, Compliance, Appeals) to resolve issues and enhance outcomes.

• Support with staff recruitment, onboarding, training, and workforce planning.

• Engage in and promote process improvement initiatives to boost efficiency, quality, and financial performance.

• Perform other assigned duties while complying with all policies and standards.

⛳️ Requirements

• Associate's Degree in Health Information Management, Nursing, or a related discipline is required.

• A minimum of 6 years of experience in MS-DRG and APR-DRG coding is required.

• At least 3 years of experience conducting DRG reviews for a Payment Integrity vendor or payer is required.

• A minimum of 3 years of experience with DRG encoder/grouper tools (such as TruCode/TruBridge, 3M, Optum Encoder, Webstrat, PSI, or similar) is required.

• Preferred: 1+ years of experience in inpatient hospital documentation improvement, complex appeal/dispute review, or auditor education/training.

• Required: RHIT - Registered Health Information Technician or CCS - Certified Coding Specialist or CIC - Certified Inpatient Coder or CCDS - Certified Clinical Documentation Specialist or RN - Registered Nurse with State Licensure and/or Compact State Licensure (combined with a coding credential) preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K and stock purchase options.

• Tuition reimbursement opportunities.

• Paid time off along with holidays.

• Flexible work arrangements including remote, hybrid, field, or office schedules.