Manager – DRG Review

Key Responsibilities

• Supervise and mentor a team of DRG Reviewers, providing guidance on coding best practices, case prioritization, and workflow management.
• Review inpatient claims imported into the DRG database to validate coding accuracy and reimbursement opportunities.
• Ensure department productivity and quality standards are achieved through monitoring, coaching, and performance evaluations.
• Collaborate with leadership to allocate resources, manage workloads, and set team priorities.
• Analyze weekly hospital billing files, identifying underpaid claims based on ICD-10 diagnosis and procedure codes.
• Provide ongoing education on ICD-10 updates, payer guidelines, and DRG reimbursement changes.
• Analyze reports to identify trends, revenue opportunities, and areas for process improvement.
• Conduct detailed medical record reviews post-bill to determine if submitted diagnosis and procedure codes are accurate and complete.
• Identify and correct errors such as under coded or misclassified diagnoses and procedures.
• Make reimbursement improvement recommendations and submit findings for client review and approval.
• Partner with internal stakeholders to ensure accurate reporting and timely delivery of client findings.
• Serve as an escalation point for complex coding or reimbursement issues.
• Stay informed on coding updates, payer guidelines, and DRG changes to support accurate recommendations.
• Identify new revenue opportunities related to all inpatient DRG related components.
• Other duties as required

Requirements & Qualifications

• Associate or bachelor’s degree in health information management or related field required. RHIT or RHIA credentialed individuals preferred.
• Certified Coding Specialist (CCS) certification required.
• 4-6 years’ experience in DRG validation, inpatient medical coding, or related coding review, with at least 1-2 years in a leadership or supervisory role.
• Strong understanding of ICD-10-CM/PCS coding guidelines, DRG reimbursement methodology, and hospital billing processes.
• Proven ability to lead, coach, and develop a high-performing team while balancing individual workload.
• Proficient in EMRs, DRG grouping software, billing databases, and MS Office applications.
• Strong analytical skills with a focus on financial impact, reimbursement accuracy, and process improvement.
• To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions.

Special Considerations and Prerequisites

• This role is primarily office-based or remote, depending on company policy, with extensive computer and document review work.
• Excellent communication skills, with the ability to interact effectively with clients and internal teams.
• Must be comfortable balancing team management with independent, detail-oriented review work.
• Analytical thinker with a focus on financial impact and reimbursement accuracy.
• Must be comfortable working independently in a detail-oriented, data-driven environment.
• Excellent communication and documentation skills to support client reporting and recommendations.
• High integrity and professionalism in handling PHI and confidential information.
• Strong collaboration and responsiveness to feedback from leadership and client partners.
• Ability to review and analyze large volumes of medical and billing data.
• Strong focus and attention to detail in identifying discrepancies and ensuring compliance.
• Ability to manage high volumes of case processing with accuracy and efficiency.
• Ability to meet deadlines and handle time-sensitive workloads in a high-volume environment.
• Proven written and verbal communication skills.
• Strong analytical and problem-solving skills.
• Ability to prioritize and manage multiple competing priorities and projects concurrently.
• Proven experience working with external clients; strong customer service skills and business acumen.
• Timely and regular attendance.