Collaborate with Payment Integrity Audit program leaders, DRG audit professionals and Data & Analytic team members to research, develop and implement inpatient DRG audit selection criteria.
Analyze performance metrics and results to ensure alignment with team goals.
Subject matter expert for research, analysis and generation of new concepts and selection rules to identify overpayment opportunities in MS DRG & APR-DRG validation.
Collaborate with internal stakeholders including the audit and analytic teams to review concepts pre-and post
implementation to monitor concept performance and identify performance issues.
Effectively utilize internal selection tools to build queries and concepts and test concept effectiveness.
Deliver results and insights to senior leaders.
Adjust selection criteria based on specific client requirements.
Responsible for monthly claim screening and selection.
Verify the selections output to ensure selection rules are functioning as intended.
Review appeals/disputes to identify areas for improvement.
Create education and training documents and conduct handoff meetings with the Audit teams to ensure understanding of new audit concepts.
Ensure the clinical team is calibrated with client policies and internal concepts.
Utilize Audit Outcome trend reports to monitor and fine-tune existing queries.

10+ years of inpatient coding or auditing experience with a mastery level expertise in both MS DRG and APR-DRG methodology.
Experience developing audit selection criteria to identify MS DRG & APR-DRG coding errors and overpayments preferred.
Experience working with large data sets.
Adept at identifying meaningful patterns, trends and root causes from data.
Advanced analytical and problem-solving skills.
Industry knowledge specific to MS DRG & APR-DRG reimbursement, provider contracts, payer policies, and audit regulations.
Excellent oral and written communication skills.
Bachelor’s degree in health information management, Healthcare Informatics or Health Care Administration.
Active AHIMA certification
RHIA, RHIT or CCS.
Experience with encoder tools (3M, Trubridge).
Proficient in Microsoft Excel including advanced functions and pivot tables and Power Point.
Experience with AI tools preferred.

Senior Manager – DRG Concept Development Analyst

Key skills