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CERIS DRG Audit Program Director
CorVel Corporation
Fort Worth (TX)
Hybrid
USD 121,000 - 158,000
Full time
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Job summary
A leading company in healthcare is seeking a CERIS DRG Audit Program Director in Fort Worth, TX. The ideal candidate will drive DRG clinical validation initiatives and lead a team focused on optimizing audit processes. This role offers a competitive salary, hybrid work environment, and robust benefits.
Benefits
Qualifications
- 7-10 years of experience in DRG coding and auditing required.
- Leadership experience in healthcare audit preferred.
- Proficient in ICD-9/10-CM/PCS coding guidelines.
Responsibilities
- Develop and execute strategic plans for the DRG audit program.
- Manage the entire DRG audit process and ensure compliance.
- Lead and mentor a team of DRG auditors.
Skills
Education
Tools
Job description
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Position Summary: The DRG Audit Program Director is a strategic and operational leader responsible for the development, implementation, and oversight of all DRG clinical validation and audit initiatives. This role ensures the integrity of healthcare payments by identifying and recovering improper payments, optimizing DRG assignments, and driving process improvements to enhance coding accuracy, documentation completeness, and compliance. The Director leads a team of clinical and coding auditors and collaborates cross-functionally with various departments to achieve organizational goals.
Key Responsibilities
- Strategic Planning & Vision:
- Develop and execute strategic plans for the DRG audit program, aligning with broader organizational objectives, industry trends, and regulatory changes (e.g., MS-DRG, APR-DRG, ICD-10-CM/PCS).
- Identify emerging risks and opportunities related to DRG assignments and develop proactive strategies to address them.
- Establish program goals, key performance indicators (KPIs), and metrics to measure effectiveness and drive continuous improvement.
- Program Management & Oversight:
- Manage the end-to-end DRG audit process, from claim selection and clinical review to audit finding generation and appeal management.
- Oversee the entire clinical claims review process, understanding various client configurations and workflows.
- Ensure adherence to established audit methodologies, policies, and procedures.
- Manage scheduling, reporting to management, issue resolution, and execution of plans.
- Perform capacity planning to ensure all Service Level Agreements (SLAs) are met regularly.
- Overall management of daily queue inventory; assign and prioritize work, set goals, and coordinate daily activities of the team.
- Team Leadership & Development:
- Lead, mentor, and develop a high-performing team of DRG coding validation, clinical validation, and readmission auditors.
- Foster a culture of accountability, innovation, and clinical excellence within the team.
- Provide guidance, counsel, and development plans to ensure long-term retention and professional growth.
- Conduct performance monitoring and provide regular feedback through one-on-one and team meetings.
- Compliance & Quality Assurance:
- Serve as a subject matter expert for DRG validation policy, audit escalation, and vendor management.
- Ensure the program complies with all relevant federal, state, and payer-specific coding, billing, and reimbursement regulations.
- Implement robust quality assurance processes to maintain high accuracy and consistency in audit findings.
- Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
- Data Analysis & Reporting:
- Utilize data-driven insights to identify trends, gaps, and emerging risks in DRG assignments.
- Manage and track data on key performance indicators (KPIs), including quality scores, workflows, savings, revenue projections, and inventory.
- Generate comprehensive audit reports, statistical analyses, and executive summaries to inform leadership and drive decision-making.
- Cross-Functional Collaboration:
- Collaborate effectively with internal stakeholders, including additional operations teams and areas outside of operations within the company
- Work with product, data analytics and technology teams to suggest and support solution development.
- Support leadership, operations, sales, and marketing teams on RFPs and new client implementations.
- Support internal and external team members by leading calls and presenting cases to varying audiences.
- Education & Training:
- Develop and deliver educational programs and training materials based on audit findings and regulatory updates to internal teams and potentially external partners.
- Serve as a resource for complex coding and clinical documentation issues.
- Education:
- Bachelor's degree in Health Information Management (HIM), Nursing, Healthcare Administration, or a related field.
- Master's degree preferred.
- Certifications:
- One or more of the following AHIMA certifications are typically required:
- Registered Health Information Administrator (RHIA)
- Registered Health Information Technician (RHIT)
- Certified Coding Specialist (CCS)
- Certified Inpatient Coder (CIC)
- Other relevant certifications (e.g., Certified Clinical Documentation Specialist - CCDS) may be preferred.
- Experience:
- Minimum of 7-10 years of progressive experience in DRG coding, clinical validation, medical auditing, or payment integrity, with a strong focus on inpatient DRGs (MS-DRG, APR-DRG, AP-DRG).
- At least 3-5 years of leadership or management experience in a healthcare audit or payment integrity setting.
- Extensive experience with ICD-9/10-CM/PCS coding guidelines, Medicare and Commercial coding rules, regulations, and prospective payment systems.
- Proven experience in managing and developing audit programs.
- Experience with Readmission reviews is a plus.
- Skills:
- Expert knowledge of clinical criteria documentation requirements and their impact on DRG assignments.
- Superior knowledge of healthcare coding, billing, and reimbursement principles.
- Strong analytical and problem-solving skills to identify trends, develop solutions, and implement action plans.
- Excellent written and verbal communication skills, with the ability to present complex information clearly and concisely to diverse audiences (clinical, technical, leadership).
- Strong leadership, interpersonal, and team-building skills.
- Proficiency in audit tools, electronic medical records (EMR) systems, abstracting systems (e.g., 3M, Epic), and Microsoft Office Suite (Word, Excel, PowerPoint).
- Ability to work efficiently and effectively with minimal supervision, manage multiple priorities, and meet deadlines.
- High standards of quality and attention to detail.
- Hybrid in office-based role in Fort Worth, TX, with remote work.
- May require occasional travel to client sites or conferences.
- Standard office environment with prolonged periods of sitting and computer use.
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: $121,571 – $157,903
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.
- Seniority levelDirector
- Employment typeFull-time
- Job functionAccounting/Auditing and Finance
- IndustriesInsurance
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