[Remote] Senior Manager - APR DRG Concept Development Analyst

Note: The job is a remote job and is open to candidates in USA. EXL is hiring an APR DRG Concept Development Analyst to research, develop, and implement inpatient DRG audit selection criteria. The role collaborates with audit and analytics teams, monitors selection performance, and analyzes results to support payment integrity goals.

Responsibilities

• Subject matter expert for research, analysis and generation of new concepts and selection rules to identify overpayment opportunities in APR-DRG validation
• Collaborates with internal stakeholders including the audit and analytic teams to review concepts pre-and post- implementation to monitor concept performance and identify performance issues
• Effectively utilizes internal selection tools to build queries and concepts and test concept effectiveness
• Deliver results and insights to senior leaders
• Adjusts selection criteria based on specific client requirements
• Responsible for monthly claim screening and selection
• Verifies the selections output to ensure selection rules are functioning as intended
• Reviews appeals/disputes to identify areas for improvement
• Creates education and training documents and conduct handoff meetings with the Audit teams to ensure understanding of new audit concepts
• Ensures the clinical team is calibrated with client policies and internal concepts
• Utilizes Audit Outcome trend reports to monitor and fine tune existing queries

Skills

• The successful candidate will be quality focused, possess strong analytical skills and have a background in payment integrity audits
• The successful candidate will demonstrate mastery-level coding skills in ICD-10-CM and PCS, along with extensive knowledge and expertise in the application of ICD-10 Official Coding Guidelines and AHA Coding Clinic guidelines
• They will possess an advanced understanding of MS DRG and APR-DRG reimbursement methodologies and remain current with relevant regulatory changes
• 10+ years of inpatient coding or auditing experience with a mastery level expertise in both APR-DRG methodology
• Experience working with large data sets
• Adept at identifying meaningful patterns, trends and root causes from data
• Advanced analytical and problem-solving skills
• Industry knowledge specific to APR-DRG reimbursement, provider contracts, payer policies, and audit regulations
• Excellent oral and written communication skills
• Bachelor's degree in health information management, Healthcare Informatics or Health Care Administration
• Active AHIMA certification - RHIA, RHIT or CCS
• Experience with encoder tools (3M, Trubridge)
• Proficient in Microsoft Excel including advanced functions and pivot tables and Power Point
• Experience developing audit selection criteria to identify APR-DRG coding errors and overpayments preferred
• Experience with AI tools preferred

Benefits

• Work From Home
• Opportunity to work closely with experienced, world-class Healthcare consultants
• Learn about many aspects of businesses that our clients engage in
• Learn effective teamwork and time management skills
• Guidance/coaching through the mentoring program, wherein every junior level employee is assigned a senior level professional as an advisor
• Further growth and development in the company and beyond
• Healthcare, Vision, Dental and 401k options

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