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CorVel Corporation · 3 months ago

DRG Clinical Payment Integrity Manager

United States

Full-time

Remote

Mid, Senior Level

$81K/yr - $125K/yr

3+ years exp

CorVel Corporation is a certified Great Place to Work® Company that provides clinical expertise and cost containment solutions in healthcare payments. They are seeking a Policy and Payment Integrity Manager to oversee the PPI team, manage team development, and ensure the accuracy of claims through trend analysis and quality assurance measures.

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 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

Qualification

RN licensureCoding licenseClaims processingDRG ValidationItemized bill reviewHealthcare revenue cycleMicrosoft OfficeComplex problem solvingInterpersonal skillsCommunication skillsAttention to detailProject management

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

Bachelor's degree in healthcare or related field

5+ years of relevant experience or equivalent combination of education and work experience

3+ years hospital bill audit

Knowledge of worker's compensation claims process

Prospective, concurrent and retrospective utilization review

Strong knowledge of itemized bill review, ASC and outpatient claim review

Ability to demonstrate understanding of CMS and commercial payer policy in written and verbal format

Strong understanding of claims processing, ICD-10 Coding, DRG Validation, 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

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

Excellent written and verbal communication skills

Proven track record of delivering concrete results in strategic projects/programs

Strong analytical and modeling ability and distilling data into actionable results

Superb attention to detail and ability to deliver results in a fast paced and dynamic environment

Preferred

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