DRG Clinical Payment Integrity Manager

DRG Clinical Payment Integrity Manager

The Policy and Payment Integrity Manager oversees the PPI team and assists with implementation of policies to perform reviews conducted by CERIS including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation. In this position, you will be managing members of the PPI team including developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress.

The manager in this role provides trend analysis of internal auditing of claims for claim accuracy related to pre and post payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review to determine the claim accuracy; assist with development of internal quality assurance measures based on client policy and industry guidelines; perform quality assurance reviews (as needed); assist in researching and implementing best practices related to payment policy, and / or policy initiatives; researching various healthcare policies; interpreting client, state, and CMS payment policies; assist in writing internal quality assurance policies; work with department managers in implementing payment policies and processes to meet quality assurance guidelines.

This is a remote role.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES :

• Assists with development and modification of standard operating procedures for PPI team.
• Utilizes healthcare and auditing experience to design, develop and implement audit criteria that are relevant and necessary for the continuous development services performed by CERIS.
• Exercises good judgment to resolve complex claim and appeal issues and makes sound decisions in the absence of detailed instructions or in an emergency situation.
• Participates in discussion with internal and external stakeholders in regards to reviews conducted by CERIS including but not limited to itemized bill review, professional review, hospital outpatient and DRG validation.
• Research, interpret and apply CMS, Federal, State and client policies to claims review
• Verbally communicate interpretation of CMS, Federal, State and client policies to providers
• Demonstrate ability to manage multiple projects, set priorities and manage to committed schedule
• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for results, innovative
• Works with operational leaders within the business to provide recommendations on opportunities for process improvements.
• Act as a resource and liaison for internal departments, account management, senior management and clients as needed
• Additional duties as assigned.

KNOWLEDGE & SKILLS :

EDUCATION / EXPERIENCE :

PAY RANGE :

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location. Pay rates are established taking into account the following factors : federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions. Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role. The level may impact the salary range and these adjustments would be clarified during the offer process.

Pay Range : $80,718 $124,624

A list of our benefit offerings can be found on our CorVel website.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.