Senior Manager - APR DRG Concept Development Analyst

As an APR DRG Concept Development Analyst, you will collaborate with Payment Integrity Audit program leaders, DRG audit professionals and Data & Analytic team members to research, develop and implement inpatient DRG audit selection criteria. This role involves analyzing performance metrics and results to ensure alignment with our team goals.

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.

Salary Range for this role is: $100k - $125k

A brief coding/auditing assessment may be included as part of the interview process.

For more information on benefits and what we offer please visit us at https://www.exlservice.com/us-careers-and-benefits

• 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.

• 10+ years of inpatient coding or auditing experience with a mastery level expertise in both APR-DRG methodology.

• Experience developing audit selection criteria to identify APR-DRG coding errors and overpayments preferred

• 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

Education and Required Certification:

• Bachelor’s degree in health information management, Healthcare Informatics or Health Care Administration
• Active AHIMA certification - RHIA, RHIT or CCS

Work Experience Requirements

• Experience with encoder tools (3M, Trubridge)
• Proficient in Microsoft Excel including advanced functions and pivot tables and Power Point
• Experience with AI tools preferred

What We Offer:

• EXL Health offers an exciting, fast paced, and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions. From your very first day, you get an opportunity to work closely with experienced, world-class Healthcare consultants.
• You can expect to learn about many aspects of businesses that our clients engage in. You will also learn effective teamwork and time management skills - key aspects for personal and professional growth.
• We provide guidance/ coaching to every employee through our mentoring program wherein every junior level employee is assigned as a senior level professional as advisors.
• Sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond.
• Benefits we offer are Healthcare, Vision, Dental and 401k options.

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.