[Hiring] Senior Manager - APR DRG Concept Development Analyst @EXL

Role Description

As an APR DRG Concept Development Analyst, you will 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. This role involves analyzing performance metrics and results to ensure alignment with our team goals.

The successful candidate will be quality focused, possess strong analytical skills, and have a background in payment integrity audits. They will demonstrate mastery-level coding skills in ICD-10-CM and PCS, along with extensive knowledge and expertise in the application of ICD-10 Official Coding Guidelines and AHA Coding Clinic guidelines. An advanced understanding of MS DRG and APR-DRG reimbursement methodologies and remaining current with relevant regulatory changes is essential.

Salary Range for this role is: $100k - $125k. A brief coding/auditing assessment may be included as part of the interview process.

Responsibilities

• Subject matter expert for research, analysis, and generation of new concepts and selection rules to identify overpayment opportunities in APR-DRG validation.
• Collaborates 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 utilizes internal selection tools to build queries and concepts and test concept effectiveness.
• Deliver results and insights to senior leaders.
• Adjusts selection criteria based on specific client requirements.
• Responsible for monthly claim screening and selection.
• Verifies the selections output to ensure selection rules are functioning as intended.
• Reviews appeals/disputes to identify areas for improvement.
• Creates education and training documents and conducts handoff meetings with the Audit teams to ensure understanding of new audit concepts.
• Ensures the clinical team is calibrated with client policies and internal concepts.
• Utilizes Audit Outcome trend reports to monitor and fine-tune existing queries.

Qualifications

• 10+ years of inpatient coding or auditing experience with mastery level expertise in both APR-DRG methodology.
• Experience developing audit selection criteria to identify 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 APR-DRG reimbursement, provider contracts, payer policies, and audit regulations.
• Excellent oral and written communication skills.

Requirements

• 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 PowerPoint.
• Experience with AI tools preferred.

Benefits

• Healthcare, Vision, Dental, and 401k options.
• Guidance/coaching through a mentoring program.
• Opportunities for personal and professional growth.