Director CERIS DRG Audit Program

CorVel Career Site•Fort Worth, TX

32d•Remote

About The Position

The Director, CERIS DRG Audit Program is a strategic and operational leader responsible for the development, implementation, and oversight of all DRG clinical validation and audit initiatives. This role ensures the integrity of healthcare payments through the identification and recovery of improper payments, optimization of DRG assignments, and continuous improvement of coding accuracy, clinical documentation, and regulatory compliance. The Director leads teams of clinical and coding auditors while collaborating across operations, policy, technology, analytics, product, sales, and client-facing functions to drive organizational performance, quality outcomes, and business growth.

Requirements

Expert knowledge of DRG validation methodologies, clinical documentation requirements, and healthcare reimbursement systems
Extensive knowledge of MS-DRG, APR-DRG, ICD-10-CM/PCS, Medicare, and commercial payer coding and reimbursement guidelines
Strong understanding of healthcare payment integrity, medical auditing, and regulatory compliance
Exceptional analytical, decision-making, and problem-solving skills
Proven ability to lead large teams, develop talent, and drive organizational performance
Excellent written, verbal, and presentation skills with the ability to communicate effectively at all organizational levels
Strong leadership, relationship-building, and stakeholder management skills
Experience leveraging data, reporting, and performance metrics to drive operational improvements
Proficiency with electronic medical record systems, audit platforms, and Microsoft Office applications
Strong organizational and project management skills with the ability to manage multiple priorities in a fast-paced environment
Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, or a related field, or equivalent experience required
Minimum of 7-10 years of progressive experience in DRG coding, clinical validation, medical auditing, or payment integrity with a focus on inpatient DRG methodologies
Minimum of 3-5 years of leadership experience in healthcare auditing, coding, clinical validation, or payment integrity operations
Extensive experience with ICD-10 coding guidelines, Medicare and commercial payer regulations, and prospective payment systems
Demonstrated success leading DRG audit programs, driving quality improvements, and delivering measurable business results

Nice To Haves

Master's degree preferred
One or more of the following certifications required or strongly preferred: RHIA, RHIT, CCS, or CIC
Additional certifications such as CCDS or other relevant clinical documentation or coding credentials preferred
Experience with readmission reviews preferred

Responsibilities

Develop and execute the strategic vision for the DRG Audit Program, ensuring alignment with organizational objectives, regulatory requirements, industry standards, and emerging trends
Provide leadership and oversight for all aspects of the DRG audit lifecycle, including clinical validation, coding validation, appeals, quality assurance, operational performance, and continuous process improvement
Establish performance goals, quality standards, key performance indicators (KPIs), and service level agreements (SLAs), utilizing data-driven insights to optimize program effectiveness, savings outcomes, and business results
Lead, develop, and mentor teams of clinical, coding, and readmission auditors while fostering a culture of accountability, collaboration, innovation, and professional growth
Serve as the organization's subject matter expert for DRG validation, clinical documentation, coding compliance, reimbursement methodologies, audit escalation management, and regulatory requirements
Partner with Operations, Policy, Product, Technology, Analytics, Sales, Client Services, and other stakeholders to improve processes, support product development, drive client success, and contribute to business growth initiatives
Provide executive-level reporting, client support, training, regulatory education, and strategic recommendations while representing the DRG Audit Program internally and externally
Travel multiple times per year as required
Additional duties as assigned