Provides strategic leadership for teams performing advanced, complex claim reviews to ensure accuracy, regulatory compliance, and achievement of payment integrity goals.
This role accelerates program growth by analyzing performance trends, standardizing processes, and implementing consistent review methodologies.
Leveraging deep expertise in ICD-10, CPT/HCPCS coding, and clinical guidelines, the manager delivers actionable insights that shape operational strategies and drive informed decision-making.
Monitoring and optimizing business processes to ensure accuracy, compliance, and integrity in billing and claims payment.
Leads and mentors high-performing teams conducting advanced coding and clinical validation reviews.
Develops and maintains standardized documentation that supports business objectives and ensures consistency in review methodologies and outcomes.
Collaborates with cross-functional stakeholders to identify process improvement opportunities and champion innovative solutions.
Establishes and oversees end-to-end audit program lifecycle within Payment Integrity by setting strategic audit direction, managing and developing teams, and ensuring compliance with all regulatory, contractual, and organizational requirements.

Associate's Degree in health information management, Nursing, or a related field required
5+ years Managerial/Supervisory experience required
8+ years Complex medical claim review experience required
3+ years DRG review experience, Clinical Documentation Improvement experience required
Proficiency ICD-10-CM/PCS, MS-DRG, APR-DRG required
Proficiency Readmission, APC, EAPG, and other review types required

Manager, Clinical & Coding Review, DRG

Key skills