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. This role manages members of the PPI team, developing team strengths and improving weaknesses, identifying team goals, and evaluating team progress.

The Policy and Payment Integrity Manager provides trend analysis of internal auditing of claims for accuracy related to pre- and post-payment claims, targeted claims, high dollar claims, and any other claim or record that requires quality review. The role assists with development of internal quality assurance measures based on client policy and industry guidelines. The manager also aids in researching and implementing best practices related to (CMS) payment policies, healthcare policies, client, state, and/or policy initiatives.

This is a remote role.

ESSENTIAL FUNCTIONS & 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 during escalations
• Participates in discussions 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
• Researches, interprets, communicates, and applies CMS, Federal, State and client policies to claims review
• Works with operational leaders within the business to recommend opportunities for process improvements
• Acts as a resource and liaison for internal departments, account management, senior management and clients, as needed
• Additional duties as assigned

KNOWLEDGE & SKILLS:

• Strong interpersonal skills and adaptive communication style, complex problem solving skills, drive for innovation and results
• Ability to manage multiple projects, set priorities and adhere to predetermined schedule
• Strong knowledge of itemized bill review, ASC, and outpatient claim review
• Understanding of CMS and commercial payer policy 
• Strong understanding of claims processing, ICD-10 Coding, DRG Validation, and Coordination of Benefits
• Strong understanding of healthcare revenue cycle and claims reimbursement
• Proficient in Microsoft Office, including Pivot Tables and Database Management
• Comfortable interfacing with clients and the C-Suite
• Excellent written and verbal communication skills
• Proven track record of delivering concrete results in strategic projects/programs
• Strong analytical skills and data-driven decision-making
• Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

EDUCATION & EXPERIENCE:

• Must maintain a current RN licensure in the state of employment
• Must maintain a current coding license (CPC, CCS, RHIT, etc.)
• 3+ years of management experience
• Minimum of 5 years’ experience in Operating Room, either as a circulating RN or scrub RN, as well as 2 years’ clinical experience in an acute care facility
• Knowledge of worker's compensation claims process
• Prospective, concurrent and retrospective utilization review
• 5+ years of relevant experience or equivalent combination of education and work experience
• 3+ years hospital bill audit
• Bachelor’s degree in healthcare or related field
• Previous experience in the following areas preferred:
  • Medical bill coding and auditing
  • DRG and Clinical Validation
  • Experience in the acute clinical areas of facilities in O.R., I.C.U., C.C.U., E.R., Telemetry, Medical/Surgical, OB or L&D, Geriatrics and Orthopedics

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 Careers | Opportunities in Risk Management

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

About CERIS

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!).

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

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

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