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CorVel Corporation · 3 months ago

DRG Clinical Payment Integrity Manager

United States

Full-time

Remote

Senior Level

$81K/yr - $125K/yr

5+ years exp

CorVel Corporation is a certified Great Place to Work® Company, dedicated to accuracy and transparency in healthcare payments. The Policy and Payment Integrity Manager oversees the PPI team, implements policies for reviews, and provides trend analysis of claims auditing for accuracy, while managing team development and process improvements.

InsuranceSoftware

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

Qualification

RN licensureCoding licenseClaims processingHealthcare revenue cycleItemized bill reviewICD-10 CodingDRG ValidationMicrosoft OfficeAnalytical skillsInterpersonal skillsProblem solvingCommunication skillsAttention to detail

Required

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

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

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