DRG Quality Manager

EXL•United States,

2d•$100,000 - $120,000•Remote

About The Position

The role directly manages a team of DRG quality analysts responsible for reviewing auditor-completed MS-DRG and APR-DRG work, validating audit accuracy, and ensuring accurate coding and reimbursement outcomes. This leader may also oversee additional quality specialties within clinical or coding audit programs. The ideal candidate demonstrates strong leadership and analytical skills, along with expertise in Coding Guidelines, Coding Clinic, audit tools, and a solid understanding of CMS regulations, payer requirements, and quality governance.

Requirements

Active coding credential required, such as CCS, RHIT, RHIA, or CPC.
5–8 years of experience with MS-DRG and APR-DRG, including strong knowledge of ICD-10-CM/PCS and Official Coding Guidelines.
Prior experience leading teams or acting in a supervisory capacity, preferably overseeing DRG quality analysts or quality teams supporting clinical or coding specialties.
Strong understanding of DRG reimbursement methodologies.
Knowledge of Medicare, Medicaid, CMS regulations, and commercial payer guidelines.
Experience working in audit, payment integrity operations, healthcare quality operations, or coding quality review.
Strong analytical skills with ability to identify trends and support decision-making.
Effective communication and interpersonal skills.
Proficiency in Microsoft Office and audit/reporting systems.
Strong analytical skills with the ability to identify trends, evaluate quality and audit performance, and support decision-making.
DRG expertise, including the ability to evaluate audit trends, identify coding or clinical documentation gaps, and translate findings into coaching, calibration, and process improvement actions.
Ability to manage quality review workflows, team capacity, review inventory, productivity, calibration, and performance to meet quality and SLA targets.
Strong attention to consistency, accuracy, and detail in quality review outcomes.
Results-oriented approach with the ability to manage multiple priorities and projects under pressure.
Excellent interpersonal skills with the ability to build positive relationships with coworkers, team members, clients, and stakeholders.
Excellent verbal, written, and presentation communication skills.
Ability to adapt to change and support evolving program, client, and operational needs.
Proficiency with Microsoft Office, dashboards, Excel, and audit/reporting systems.

Nice To Haves

Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred.

Responsibilities

Support the execution and ongoing improvement of DRG quality review programs, including readmissions and place of service reviews.
Partner with cross-functional teams, including technology, operations, and training, to support implementation of audit quality solutions.
Oversee day-to-day quality review operations, ensuring alignment with client SLAs, quality expectations, productivity goals, and internal standards.
Manage quality review inventory, workflow distribution, QA aging, and productivity to ensure timely completion of quality reviews.
Provide direct supervision to DRG quality analysts and, as needed, quality analysts supporting other clinical or coding quality specialties, through coaching, feedback, and performance management.
Ensure adherence to productivity, quality, accuracy, and SLA standards.
Monitor regulatory and payer guideline updates, ensuring quality reviews remain compliant and current.
Support performance management processes, including one-on-ones, training, and development planning.
Identify quality, operational, and process gaps and drive improvement initiatives.
Escalate and help resolve client, quality, auditor performance, or operational issues as needed.
Support reporting activities, including productivity, quality, audit accuracy, QA inventory, and defect trend metrics.
Assist with program implementations and operational initiatives by defining quality expectations, review criteria, and quality control processes.
Ensure consistency and alignment across quality analysts, programs, Operations, Training, and global partners.
Facilitate ongoing development, knowledge depth, and upskilling of quality analysts.