Director, Pre-bill DRG Validation Program

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🔴 Lead

👔 Director

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CorroHealth

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

☁️ SaaS

Healthcare • Healthcare Insurance • SaaS

CorroHealth is a leading provider of clinically led healthcare analytics and technology-driven solutions, focused on enhancing the financial performance of hospitals and health systems. Their integrated solutions and advanced technologies aim to optimize the entire revenue cycle, offering services such as revenue cycle management, clinical documentation, medical coding, and denials management. With a commitment to improving financial health through intelligent technology and expert guidance, CorroHealth addresses complex payer-provider relationships and supports efficient healthcare operations.

📋 Description

• Own the end-to-end design, execution, and continuous improvement of the pre-bill DRG validation program across assigned client engagements • Establish program goals, KPIs, and service-level commitments; report performance to executive leadership and clients • Develop and maintain review methodologies, case selection logic, and prioritization criteria • Identify opportunities to expand service offerings and support business development through subject-matter expertise, proposal input, and client presentations • Serve as senior clinical and coding authority for DRG validation, clinical validation, and query practice • Ensure reviews comply with ICD-10-CM/PCS Official Guidelines, AHA Coding Clinic, CMS regulations, ACDIS/AHIMA query guidelines, and payer policies • Adjudicate escalated and complex cases, including clinical validation disputes, conflicting documentation, and high-dollar DRG shifts • Maintain a quality assurance program with inter-rater reliability targets, second-level review, and corrective action • Recruit, onboard, develop, and retain clinical validators, DRG auditors, and CDI professionals • Set productivity and quality expectations; conduct evaluations; manage coaching, development plans, and corrective action • Design and deliver education on regulatory changes, coding updates, and clinical validation topics • Manage staffing models, capacity planning, and workload distribution • Act as executive point of contact for client HIM, CDI, Compliance, and Revenue Cycle leadership • Lead client governance meetings, present outcomes and trend analyses, and provide documentation and coding improvement recommendations • Resolve client escalations and manage program changes, scope adjustments, and issue remediation • Ensure compliance with HIPAA, OIG guidance, and CorroHealth policies; support audits • Partner with Analytics on dashboards and reporting for DRG changes, financial impact, query response, denials, and reviewer performance • Collaborate with Technology and Product teams on workflow tooling, case routing, and automation • Manage program budget, labor costs, vendor relationships, and profitability targets

🎯 Requirements

• Registered Nurse (BSN or ADN with active licensure), Doctor of Medicine (MD/DO), Physician Assistant, Nurse Practitioner, or equivalent clinical credential from an accredited institution • Bachelor's degree required • Master's degree (MSN, MHA, MBA, or related) preferred • CDI certification: CCDS (ACDIS) or CDIP (AHIMA) required • Coding certification: CCS (AHIMA) preferred • Minimum 10 years of hands-on experience performing and/or overseeing DRG validation reviews, including MS-DRG and APR-DRG methodologies, clinical validation, and pre-bill review workflows • Minimum 5 years of people management experience leading clinical, coding, or CDI teams, including direct supervision of managers or team leads • Experience managing programs in a hospital, health system, payer, or healthcare consulting/outsourcing environment • Proven track record of delivering measurable financial and quality outcomes through DRG validation or CDI programs • Expert command of ICD-10-CM/PCS, MS-DRG and APR-DRG grouping logic, CC/MCC capture, SOI/ROM, and Coding Clinic guidance • Deep understanding of compliant query practice, clinical validation standards, and payer denial and appeal processes • Strong analytical skills and ability to interpret program data and present findings to executive and clinical audiences • Executive presence, exceptional written and verbal communication, and ability to influence physicians, HIM, and finance leaders • Proficiency with encoders, CDI platforms, and EHR systems such as 3M/Solventum, Epic, and Cerner/Oracle Health • Standard business hours with flexibility to support client time zones and deadlines • Preferred: experience in a multi-client outsourced services or consulting environment • Preferred: experience building or scaling a pre-bill or concurrent review program from inception • Preferred: experience with pediatric, academic medical center, or specialty inpatient populations • Preferred: familiarity with AI-assisted coding or CDI technologies and governance • Preferred: Six Sigma, Lean, or PMP certification

🏖️ Benefits

• Annual performance-based bonus • Comprehensive medical, dental, and vision coverage • 401(k) with company match • Paid time off and holidays • Continuing education and certification maintenance support • Remote work arrangement • Flexibility to support client time zones and deadlines