[Hiring] Manager, Inpatient Audit @Blue Cross Blue Shield of Massachusetts

Role Description

This role is eligible for the following personas: [Flex, Remote/Mobile/Eworker]. Reporting to the Associate Director of the Enterprise Payment Integrity Office, the Inpatient Audit Manager is responsible for leading a team of diagnostic-related group (DRG) validation auditors. This team utilizes advanced data analytics and proprietary algorithms to perform pre-payment and post-payment DRG and clinical validation reviews, identifying payment integrity issues, billing discrepancies, and revenue recovery opportunities.

As a subject matter expert in health care coding and billing, DRG grouping methodologies (MS-DRG and APR-DRG), and inpatient clinical documentation, the Inpatient Audit Manager must possess a strong clinical foundation (preferably a nursing degree or equivalent clinical and billing background).

The Inpatient Audit Manager drives daily business operations, including trend analysis, medical record review findings, and team performance measurement. This role serves as a key cross-functional collaborator with internal business units—such as Fraud Investigation and Prevention, Health and Medical Management (including Medical Directors), and Network Management—as well as the external provider community. The successful candidate will build and maintain strong relationships within a matrixed environment and exercise independent decision-making with considerable latitude regarding audit selections, clinical determinations, and provider appeals.

Your Day to Day

• Direct, manage, and mentor a team of six DRG validation auditors performing pre-pay and post-pay clinical validation and DRG reviews.
• Verify the accuracy of inpatient claims reimbursement, clinical significance, medical necessity, coding, and billing in accordance with plan agreements and coding guidelines.
• Foster a culture of accountability, operational excellence, and continuous development. Coach, counsel, and evaluate direct reports to maximize performance, job progression, and organizational impact.
• Oversee pre-payment and post-payment DRG validations and clinical audits, applying clinical, regulatory, and contractual expertise to identify overpayments and underpayments.
• Utilize grouper software with advanced proficiency, and oversee internal audit inventory, platforms, and automated editing workflows.
• Analyze complex audit datasets, evaluating performance (such as APR-DRG upgrades and logic shifts), identifying emerging hospital billing patterns, and leveraging data to optimize audit selection criteria and productivity standards.
• Interface directly with provider leaders and clinical staff to discuss documentation-related determinations and audit close findings. Formulate comprehensive appeal disposition rationales substantiated by national coding criteria sets, clinical evidence, and applicable regulatory frameworks.
• Lead complex provider discussions and dispute resolutions with empathy, clarity, and professionalism. Proactively resolve billing conflicts and establish collaborative pathways to foster provider compliance and reduce unnecessary abrasion.
• Represent the Enterprise Payment Integrity Office on cross-functional initiatives and governance workgroups. Partner with corporate stakeholders to identify cost-containment opportunities, mitigate medical trend growth, and integrate cutting-edge automated audit and analytics solutions.
• Advocate for innovative audit methodologies, championing cost-avoidance strategies, and aligning departmental targets with overarching enterprise financial and service goals.

Qualifications

• 5+ years of operational management or team leadership experience in health care operations, payment integrity, or clinical audit.
• 5+ years of hands-on experience in medical billing and coding, with deep technical expertise in MS-DRG, APR-DRG, and ICD-10-CM/PCS methodologies.
• Comprehensive background in health plan operations across Commercial and Medicare Advantage lines of business.

Requirements

• Advanced proficiency in grouper applications and audit management software.
• Working knowledge of claims processing platforms and enterprise data warehouse environments (e.g., Datawarehouse, NASCO).
• Familiarity with major Electronic Medical Record (EMR) systems and electronic clinical data interchange.
• Advanced analytical, problem-solving, and root-cause analysis skills.
• Strong project management acumen with the ability to manage competing priorities and high-volume workloads.
• Superior written and oral communication skills, including the ability to synthesize handwritten or complex digital medical records into concise clinical rationales.
• Ability to work effectively both independently and collaboratively across a matrixed enterprise.

What You Bring

• Bachelor’s Degree (BS/BA) required.
• Clinical degree (e.g., BSN/RN) is strongly preferred.
• Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) required.

Benefits

• Comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.