Senior Manager - APR DRG Concept Development Analyst

EXL; Oregon; Hybrid; USD 100,000 - 125,000; Full time

Benefits offered by this job

Healthcare

Vision

Dental

401k

Job summary

EXL Health is seeking an APR DRG Concept Development Analyst to collaborate with Payment Integrity Audit program leaders and DRG audit professionals to research, develop and implement inpatient DRG audit criteria. The role emphasizes mastery-level ICD-10-CM/PCS coding and APR-DRG methodologies, with a focus on quality and analytical rigor.

The position includes a salary range of $100,000–$125,000 and may involve an interview assessment. Benefits information is available on our site.

Qualifications

• Bachelor's degree in health information management, Healthcare Informatics or Health Care Administration.
• Active AHIMA certification - RHIA, RHIT or CCS.
• 10+ years of inpatient coding or auditing experience with mastery in APR-DRG methodology.
• Experience developing audit selection criteria to identify APR-DRG coding errors and overpayments.

Responsibilities

• Subject matter expert for research, analysis and generation of new concepts and selection rules to identify overpayment opportunities in APR-DRG validation.
• Collaborates with audit and analytic teams to review concepts pre-and post-implementation to monitor performance.
• Build queries and concepts, test concept effectiveness using internal selection tools.
• Deliver results and insights to senior leaders.
• Adjust selection criteria based on client requirements.
• Responsible for monthly claim screening and selection.
• Verify selections output to ensure rules function as intended.
• Review appeals/disputes to identify areas for improvement.
• Create education/training documents and conduct handoff meetings with Audit teams.
• Ensure clinical team is calibrated with client policies and internal concepts.
• Utilize Audit Outcome trend reports to monitor and fine tune queries.

Skills

APR-DRG mastery

ICD-10-CM coding

ICD-10-PCS coding

Data analysis

Audit concepts

Communication skills

Education

Bachelors in HIM/Health Informatics/Healthcare Admin

AHIMA RHIA/RHIT/CCS certification

Tools

3M Encoder

TruBridge

Excel

PowerPoint

AI tools

Job description

As an APR DRG Concept Development Analyst, you will collaborate with Payment Integrity Audit program leaders, DRG audit professionals and Data & Analytic team members to research, develop and implement inpatient DRG audit selection criteria. This role involves analyzing performance metrics and results to ensure alignment with our team goals.The successful candidate will be quality focused, possess strong analytical skills and have a background in payment integrity audits. The successful candidate will demonstrate mastery-level coding skills in ICD-10-CM and PCS, along with extensive knowledge and expertise in the application of ICD-10 Official Coding Guidelines and AHA Coding Clinic guidelines. They will possess an advanced understanding of MS DRG and APR-DRG reimbursement methodologies and remain current with relevant regulatory changes.

Salary Range for this role is: $100k - $125kA brief coding/auditing assessment may be included as part of the interview process.For more information on benefits and what we offer please visit us at

Responsibilities

• Subject matter expert for research, analysis and generation of new concepts and selection rules to identify overpayment opportunities in APR-DRG validation
• Collaborates with internal stakeholders including the audit and analytic teams to review concepts pre-and post- implementation to monitor concept performance and identify performance issues
• Effectively utilizes internal selection tools to build queries and concepts and test concept effectiveness
• Deliver results and insights to senior leaders
• Adjusts selection criteria based on specific client requirements
• Responsible for monthly claim screening and selection
• Verifies the selections output to ensure selection rules are functioning as intended
• Reviews appeals/disputes to identify areas for improvement.
• Creates education and training documents and conduct handoff meetings with the Audit teams to ensure understanding of new audit concepts
• Ensures the clinical team is calibrated with client policies and internal concepts.
• Utilizes Audit Outcome trend reports to monitor and fine tune existing queries.

Qualifications

• 10+ years of inpatient coding or auditing experience with a mastery level expertise in both APR-DRG methodology.
• Experience developing audit selection criteria to identify APR-DRG coding errors and overpayments preferred
• Experience working with large data sets.
• Adept at identifying meaningful patterns, trends and root causes from data
• Advanced analytical and problem-solving skills.
• Industry knowledge specific to APR-DRG reimbursement, provider contracts, payer policies, and audit regulations
• Excellent oral and written communication skills

Education and Required Certification

• Bachelor's degree in health information management, Healthcare Informatics or Health Care Administration
• Active AHIMA certification - RHIA, RHIT or CCS

Work Experience Requirements

• Experience with encoder tools (3M, Trubridge)
• Proficient in Microsoft Excel including advanced functions and pivot tables and Power Point
• Experience with AI tools preferred

What We Offer

• EXL Health offers an exciting, fast paced, and innovative environment, which brings together a group of sharp and entrepreneurial professionals who are eager to influence business decisions. From your very first day, you get an opportunity to work closely with experienced, world-class Healthcare consultants.
• You can expect to learn about many aspects of businesses that our clients engage in. You will also learn effective teamwork and time management skills - key aspects for personal and professional growth.
• We provide guidance/ coaching to every employee through our mentoring program wherein every junior level employee is assigned as a senior level professional as advisors.
• Sky is the limit for our team members. The unique experiences gathered at EXL Health sets the stage for further growth and development in our company and beyond.
• Benefits we offer are Healthcare, Vision, Dental and 401k options.

The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.

EXL (NASDAQ: EXLS) is a leading data analytics and digital operations and solutions company. We partner with clients using a data and AI-led approach to reinvent business models, drive better business outcomes and unlock growth with speed. EXL harnesses the power of data, analytics, AI, and deep industry knowledge to transform operations for the world's leading corporations in industries including insurance, healthcare, banking and financial services, media and retail, among others. EXL was founded in 1999 with the core values of innovation, collaboration, excellence, integrity and respect. We are headquartered in New York and have more than 54,000 employees spanning six continents.

EXL will only extend a job offer after a candidate has gone through a formal interview process with members of EXL's Human Resources team, as well as our hiring managers.

EXL is the indispensable partner for leading businesses in data-led industries such as insurance, banking and financial services, healthcare, retail and logistics. We bring a unique combination of data, advanced analytics, digital technology and industry expertise to help our clients turn data into insights, streamline operations, improve customer experience, and transform their business. Our partnerships with clients are built on a foundation of collaboration - and we've been chosen as a partner by nine of the top ten leading US insurance companies, nine of the top 20 global banks, and six of the top ten US health care payers. We function as one team to make your goals our goals, whether that's unlocking the value of generative AI or embedding analytics into workflows that reduce risk or power your growth. Clients choose EXL as their transformation partner for many reasons. Our geographic diversity make talent all over the world instantly accessible. Digital accelerators enable unmatched speed-to-value, letting you realize results fast. It's our people that truly set us apart, though, including the 1,500 data scientists we have dedicated to our generative AI practice. And our more than twenty years of experience in delivering business services, garnering stellar client references, and maintaining a solid balance sheet are reassuring to our C-suite clients. Find out for yourself why clients, employees, and analysts think we're some of the best in the business. Contact us to see how we can help you achieve your goals.