Manager, Inpatient Audit

Blue Cross MA; Hingham (MA); On-site; USD 117,000 - 143,000; Full time

Benefits offered by this job

Medical/dental/vision insurance

401(k) plan

Job summary

Blue Cross and Blue Shield of Massachusetts Inc. seeks an Inpatient Audit Manager to lead six DRG validation auditors in a data-driven, high-volume inpatient audit environment.

You will oversee pre-pay and post-pay DRG reviews, ensuring medical necessity and coding accuracy across Commercial and Medicare Advantage lines. Ideal candidates bring 5+ years of healthcare operations leadership, strong MS-DRG/APR-DRG knowledge, and experience with grouper tools and EMR data.

Qualifications

• 5+ years of operational management or team leadership in healthcare operations or clinical audit.
• 1+ year hands-on medical billing and coding experience with MS-DRG/APR-DRG.

Responsibilities

• Direct, manage, and mentor a team of six DRG validation auditors.

Skills

Analytical skills

Problem-solving

Project management

Communication skills

Education

Bachelor’s Degree (BS/BA)

Clinical degree preferred (BSN/RN)

Tools

Grouper software

Audit management software

EMR systems knowledge

Job description

Manager, Inpatient Audit### Manager, Inpatient AuditApply: Hingham: Full time: Posted Yesterday: R09063## **Ready to help us transform healthcare? Bring your true colors to blue.****About the Role:***This role is eligible for the following personas: [Flex, Remote/Mobile/Eworker].*Reporting to the Associate Director of the Enterprise Payment Integrity Office, the Inpatient Audit Manager is responsible for leading a team of diagnostic-related group (DRG) validation auditors. This team utilizes advanced data analytics and proprietary algorithms to perform pre-payment and post-payment DRG and clinical validation reviews, identifying payment integrity issues, billing discrepancies, and revenue recovery opportunities.As a subject matter expert in health care coding and billing, DRG grouping methodologies (MS-DRG and APR-DRG), and inpatient clinical documentation, the Inpatient Audit Manager must possess a strong clinical foundation (preferably a nursing degree or equivalent clinical and billing background).The Inpatient Audit Manager drives daily business operations, including trend analysis, medical record review findings, and team performance measurement. This role serves as a key cross-functional collaborator with internal business units—such as Fraud Investigation and Prevention, Health and Medical Management (including Medical Directors), and Network Management—as well as the external provider community. The successful candidate will build and maintain strong relationships within a matrixed environment and exercise independent decision-making with considerable latitude regarding audit selections, clinical determinations, and provider appeals.**Your Day to Day:**1. Direct, manage, and mentor a team of six DRG validation auditors performing pre-pay and post-pay clinical validation and DRG reviews.2. Verify the accuracy of inpatient claims reimbursement, clinical significance, medical necessity, coding, and billing in accordance with plan agreements and coding guidelines3. Foster a culture of accountability, operational excellence, and continuous development. Coach, counsel, and evaluate direct reports to maximize performance, job progression, and organizational impact4. Oversee pre-payment and post-payment DRG validations and clinical audits, applying clinical, regulatory, and contractual expertise to identify overpayments and underpayments.5. Utilize grouper software with advanced proficiency, and oversee internal audit inventory, platforms, and automated editing workflows.6. Analyze complex audit datasets, evaluating performance (such as APR-DRG upgrades and logic shifts), identifying emerging hospital billing patterns, and leveraging data to optimize audit selection criteria and productivity standards.7. Interface directly with provider leaders and clinical staff to discuss documentation-related determinations and audit close findings. Formulate comprehensive appeal disposition rationales substantiated by national coding criteria sets, clinical evidence, and applicable regulatory frameworks8. Lead complex provider discussions and dispute resolutions with empathy, clarity, and professionalism. Proactively resolve billing conflicts and establish collaborative pathways to foster provider compliance and reduce unnecessary abrasion9. Represent the Enterprise Payment Integrity Office on cross-functional initiatives and governance workgroups. Partner with corporate stakeholders to identify cost-containment opportunities, mitigate medical trend growth, and integrate cutting-edge automated audit and analytics solutions10. Advocate for innovative audit methodologies, championing cost-avoidance strategies, and aligning departmental targets with overarching enterprise financial and service goalsThis document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Employees may be required to perform other job-related duties.**We’re Looking For:**Professional Experience:* 5+ years of operational management or team leadership experience in health care operations, payment integrity, or clinical audit.* 5+ years of hands-on experience in medical billing and coding, with deep technical expertise in MS-DRG, APR-DRG, and ICD-10-CM/PCS methodologies.* Comprehensive background in health plan operations across Commercial and Medicare Advantage lines of business.Technical Skills:* Advanced proficiency in grouper applications and audit management software.* Working knowledge of claims processing platforms and enterprise data warehouse environments (e.g., Datawarehouse, NASCO).* Familiarity with major Electronic Medical Record (EMR) systems and electronic clinical data interchange.Core Competencies:* Advanced analytical, problem-solving, and root-cause analysis skills.* Strong project management acumen with the ability to manage competing priorities and high-volume workloads.* Superior written and oral communication skills, including the ability to synthesize handwritten or complex digital medical records into concise clinical rationales.* Ability to work effectively both independently and collaboratively across a matrixed enterprise.**What You Bring:**Education:* Bachelor’s Degree (BS/BA) required.* Clinical degree (e.g., BSN/RN) is strongly preferred.Professional Certifications:* Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) required.What You’ll Gain:You will elevate your professional profile by serving as a key leader to a specialized team of DRG validators and a key contributor to advancing Inpatient audit through modernized technology and proprietary algorithms.## Minimum Education Requirements:High school degree or equivalent required unless otherwise noted above## LocationHingham## Time TypeFull timeSalary Range: $117,355.98 - $143,440.00 The job posting range is the lowest to highest salary we in good faith believe we would pay for this role at the time of this posting. We may ultimately pay more or less than the posted range, and the range may be modified in the future. An employee’s pay position within the salary range will be based on several factors including, but limited to, relevant education, qualifications, certifications, experience, skills, performance, shift, travel requirements, sales or revenue-based metrics, and business or organizational needs and affordability.This job is also eligible for variable pay.We offer comprehensive package of benefits including paid time off, medical/dental/vision insurance, 401(k), and a suite of well-being benefits to eligible employees.Note: No amount of pay is considered to be wages or compensation until such amount is earned, vested, and determinable. The amount and availability of any bonus, commission, or any other form of compensation that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.