Senior Manager - APR DRG Concept Development Analyst

EXL•United States,

11d•$100,000 - $125,000

About The Position

The APR DRG Concept Development Analyst collaborates with Payment Integrity Audit program leaders, DRG audit professionals, and Data & Analytics team members to research, develop, and implement inpatient DRG audit selection criteria. The role analyzes performance metrics and results to ensure alignment with team goals and applies expertise in payment integrity audits, ICD-10-CM and PCS coding, coding guidelines, and MS DRG and APR-DRG reimbursement methodologies. The position also monitors regulatory changes and uses audit outcome trends to evaluate and improve selection concepts. The role is responsible for identifying APR-DRG validation overpayment opportunities, building and testing selection concepts, screening claims, and verifying selection outputs. It involves collaboration with audit, analytic, and clinical teams, adapting criteria to client requirements, communicating findings to senior leaders, reviewing appeals and disputes, and preparing training materials and handoffs for audit teams. The posted base salary range is $100,000–$125,000. A brief coding or auditing assessment may be part of the interview process. EXL describes an innovative, fast-paced environment with mentoring and opportunities for professional growth. Benefits listed include healthcare, vision, dental, and 401(k) options.

Requirements

At least 10 years of inpatient coding or auditing experience, with mastery-level expertise in APR-DRG methodology.
Bachelor’s degree in health information management, healthcare informatics, or healthcare administration.
Active AHIMA certification: RHIA, RHIT, or CCS.
Mastery-level ICD-10-CM and PCS coding skills and extensive knowledge of ICD-10 Official Coding Guidelines and AHA Coding Clinic guidelines.
Advanced understanding of MS DRG and APR-DRG reimbursement methodologies and awareness of relevant regulatory changes.
Experience working with large data sets.
Ability to identify meaningful data patterns, trends, and root causes.
Advanced analytical and problem-solving skills.
Industry knowledge of APR-DRG reimbursement, provider contracts, payer policies, and audit regulations.
Excellent oral and written communication skills.
Experience with encoder tools such as 3M or TruBridge.
Proficiency in Microsoft Excel, including advanced functions and pivot tables, and PowerPoint.

Nice To Haves

Experience developing audit selection criteria to identify APR-DRG coding errors and overpayments.
Experience with AI tools.

Responsibilities

Research, analyze, and generate new concepts and selection rules to identify overpayment opportunities in APR-DRG validation.
Collaborate with audit and analytics stakeholders to review concepts before and after implementation, monitor performance, and identify performance issues.
Use internal selection tools to build queries and concepts and test their effectiveness.
Deliver results and insights to senior leaders.
Adjust selection criteria to meet specific client requirements.
Conduct monthly claim screening and selection.
Verify selection outputs to ensure selection rules are functioning as intended.
Review appeals and disputes to identify areas for improvement.
Create education and training documents and conduct handoff meetings with audit teams to support understanding of new audit concepts.
Ensure the clinical team is calibrated with client policies and internal concepts.
Use audit outcome trend reports to monitor and fine-tune existing queries.