Manager, Inpatient Audit

Blue Cross Blue Shield of Massachusetts•Hingham, MA

1d•$117,356 - $143,440

About The Position

The Inpatient Audit Manager leads a team of diagnostic-related group (DRG) validation auditors who use advanced data analytics and proprietary algorithms to conduct pre-payment and post-payment DRG and clinical validation reviews. The team identifies payment integrity issues, billing discrepancies, and revenue recovery opportunities. The manager is a subject matter expert in health care coding and billing, MS-DRG and APR-DRG grouping methodologies, and inpatient clinical documentation, with a strong clinical foundation preferred. Reporting to the Associate Director of the Enterprise Payment Integrity Office, the manager oversees daily operations, trend analysis, medical-record review findings, and team performance. The role collaborates with internal business units—including Fraud Investigation and Prevention, Health and Medical Management, Medical Directors, and Network Management—as well as the external provider community. It calls for strong relationship-building in a matrixed environment and independent decision-making on audit selections, clinical determinations, and provider appeals. The role is based in Hingham and is eligible for Flex, Remote/Mobile/Eworker personas. It is full-time and offers a salary range of $117,355.98 to $143,440.00, with eligibility for variable pay. The company offers paid time off, medical, dental, and vision insurance, 401(k), and well-being benefits to eligible employees.

Requirements

At least 5 years of operational management or team leadership experience in health care operations, payment integrity, or clinical audit.
At least 5 years of hands-on medical billing and coding experience, 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.
Advanced proficiency in grouper applications and audit management software.
Working knowledge of claims processing platforms and enterprise data warehouse environments, such as Datawarehouse and NASCO.
Familiarity with major electronic medical record (EMR) systems and electronic clinical data interchange.
Advanced analytical, problem-solving, and root-cause analysis skills.
Project management skills, including the ability to manage competing priorities and high-volume workloads.
Strong written and oral communication skills, including the ability to synthesize handwritten or complex digital medical records into concise clinical rationales.
Ability to work independently and collaboratively across a matrixed enterprise.
Bachelor’s degree (BS/BA) required.
Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) certification required.
High school degree or equivalent required unless otherwise noted.

Nice To Haves

Clinical degree, such as BSN/RN, is strongly preferred.

Responsibilities

Direct, manage, and mentor a team of six DRG validation auditors conducting 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 accountability, operational excellence, and continuous development; coach, counsel, and evaluate direct reports.
Oversee pre-payment and post-payment DRG validations and clinical audits, applying clinical, regulatory, and contractual expertise to identify overpayments and underpayments.
Use grouper software and oversee internal audit inventory, platforms, and automated editing workflows.
Analyze audit datasets and performance, identify emerging hospital billing patterns, and use data to optimize audit selection criteria and productivity standards.
Discuss documentation-related determinations and audit findings with provider leaders and clinical staff, and formulate appeal disposition rationales supported by coding criteria, clinical evidence, and regulatory frameworks.
Lead provider discussions and dispute resolutions, resolve billing conflicts, and promote provider compliance while reducing unnecessary abrasion.
Represent the Enterprise Payment Integrity Office on cross-functional initiatives and governance workgroups; partner with corporate stakeholders on cost containment, medical trend mitigation, and automated audit and analytics solutions.
Advocate for innovative audit methodologies and cost-avoidance strategies, aligning departmental targets with enterprise financial and service goals.