DRG Manager

Accountabilities: Lead the development, enhancement, and review of clinical payment solutions, including MS-DRG, APR-DRG, readmission, place-of-service, and related programs. Oversee the end-to-end clinical claims review process, accounting for different client configurations, workflows, requirements, and payment methodologies. Collaborate with programmers, auditors, operations, product leaders, data analysts, and technology teams to take DRG concepts from initial development through implementation. Monitor regulatory changes and evaluate the effectiveness of written rules, making updates when necessary to maintain accurate and compliant review methodologies. Lead and develop the DRG team by providing guidance, coaching, performance feedback, and professional development plans. Assign and prioritize team workloads, establish goals, coordinate daily activities, and ensure timely delivery against departmental standards. Monitor individual and team performance, quality results, productivity, inventory, workflows, savings, and revenue projections. Develop and maintain departmental policies, processes, training standards, and operational best practices. Analyze claims data to identify problems, trends, root causes, and opportunities for improved payment accuracy. Design and deploy programs that identify and correct claims with aberrant results while providing feedback that helps address underlying causes. Provide internal and external stakeholders with supporting evidence, references, industry standards, audit guidance, and rationale for review decisions. Establish project timelines, track progress, communicate dependencies, and escalate roadblocks to keep initiatives on schedule. Support client-facing activities, implementation efforts, special projects, research, and ad hoc claim reviews as needed. Share DRG audit expertise across sales, marketing, development, and other teams to strengthen organizational understanding of payment integrity solutions. Requirements Bachelor’s degree in health administration, business, nursing, or a related field, or equivalent relevant professional experience. 5+ years of experience in healthcare billing and coding, with at least 3 years of experience in claims auditing and recovery auditing. Demonstrated expertise in DRG validation, particularly APR-DRG and MS-DRG methodologies. Strong knowledge of classification and payment systems, including MS-DRG, APR-DRG, AP-DRG, APCs, EAPGs, and related outpatient payment methodologies. Deep understanding of Medicare and commercial coding rules, reimbursement regulations, and prospective payment systems. Strong knowledge of healthcare coding, billing, reimbursement, clinical criteria, and documentation requirements. Experience with readmission reviews and place-of-service review methodologies. Familiarity with Milliman and InterQual guidelines. Experience managing production operations and teams, including assigning work, monitoring performance, setting goals, and developing team members. Demonstrated ability to use data and analytical insights to identify trends, investigate root causes, and develop actionable solutions. Experience independently structuring and executing complex analyses with a high degree of accuracy. Strong problem-solving skills, curiosity, and a demonstrated ability to understand the underlying causes of healthcare payment and claims issues. Excellent attention to detail and consistently high standards for quality. Ability to work independently with minimal supervision while collaborating effectively across multidisciplinary teams. Strong written and verbal communication skills, with the ability to explain technical audit and payment concepts to diverse stakeholders. Proven ability to manage multiple priorities, meet deadlines, and adapt effectively to changing business requirements. Benefits $125,000–$140,000 USD base salary range, plus an annual bonus. Meaningful equity as part of the overall compensation package. Fully remote work from anywhere in the United States. Medical, dental, and vision insurance options. Flexible Spending Account (FSA) and Health Savings Account (HSA) options. 401(k) retirement plan with company match. Tuition reimbursement. Unlimited paid time off. Additional health and wellness benefits and perks. Flexible, trust-based working environment designed to give employees autonomy and ownership. Equal employment opportunity and reasonable accommodation support throughout the recruitment process.