DRG Clinical Support Lead

Machinify • Roseville, CA

1d • $120,000 - $145,000 • Remote

About The Position

The DRG Clinical Support Lead is responsible for the development and management of our clinical solutions, including Readmissions, MS-DRG, and APR-DRG validation clinical concepts. This role will also take part in managing the selection process, volume, and results, across platforms. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims recovery, and MS & APR-DRG expertise is essential. Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed for proof of concepts. This role also will be responsible for managing selections across platforms and ensuring accuracy of scope and monitoring and adjustment of volume and results. This role requires an expert in clinical areas in addition to payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance.

Requirements

• Bachelor’s degree (health administration, business, nursing)
• Equivalent experience of 5+ years in healthcare billing and coding
• Equivalent experience of 3+ years in claims auditing and recovery auditing
• Extensive experience in MS-DRG and APR-DRG methodology for clinical content rules development and claim selections
• Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
• Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs
• Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
• Strong experience in data utilization and insights
• Experience independently structuring and executing complex analyses
• Familiarity with Milliman and InterQual guidelines
• Expertise in DRG validation
• Experience in production and team management
• Experience with Readmission reviews
• Ability to work efficiently and effectively with minimal supervision
• High standards of quality and attention to detail
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
• Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures
• Expert knowledge of clinical criteria documentation requirements
• Subject matter expertise in MS & APR-DRG validation, and Readmissions
• Experience providing clinical support during peer-to-peer reviews and client reviews
• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficient in Windows office systems, including the full Microsoft Suite and Teams
• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various software applications and collaboration with development teams
• Familiarity with multiple encoder/grouper applications
• Ability to sit or stand for long periods, with occasional stooping and reaching
• May require lifting up to 25 pounds
• Requires a normal range of vision and hearing, with or without accommodations
• Position is not substantially exposed to adverse environmental conditions

Responsibilities

• Content Development: Develop innovative strategies to enhance claim selection processes for both pre- and post-payment, significantly contributing to payment integrity for our clients.
• Data Analysis and Organization: Leverages data analysis expertise and strong organizational skills to innovate and optimize proprietary tools, ensuring the highest standards of payment accuracy.
• Claim Selection Methodology: Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
• Claim Selection Management: Manage and monitor selections across business and ensure appropriate volume and cadence.
• Enhance and Review Clinical Solutions: Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
• Collaborative Development: Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
• Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
• Performance Monitoring: Monitor performance of current and new concepts and continue to adjust to enhance performance and output.
• Analytical Problem-Solving: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
• Policy and Process Development: Develop departmental policies, processes, and training standards.
• Support and Evidence: Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
• Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
• Program Deployment: Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
• Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
• Proof of Concept Assistance: When necessary, provide review support for proof of concepts or sales support.
• Other Duties: Perform other duties as assigned.

Benefits

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees