The Senior Manager Diagnosis Related Group (DRG) SME will support the business team in evaluating trends on utilization of products / services based on historical data - such as care management trends, claim utilization, member attributes, to develop cost effective quality product / services. The ideal candidate retrieves, organizes and performs research/analysis on Medical Health Claim data primarily to identify root cause and is a proactive thinker, self-starter, who enjoys working in a fast-paced and challenging environment with the ability to work independently. Candidate should have a strong understanding of both inpatient MS-DRG/APR-DRG payment systems and have experience/knowledge in health care claims. Additional experience with Outpatient, HH, SNF, BH, IRF, Professional, DME, HCD claims is a plus. Previous claims payment and auditing experience would also be beneficial and recommended. Understanding of Medical claim terminology and insurance terminology. Experience with payer policy, claim system limitations, provider contracting terms are highly recommended. Experience with Pre-Pay and Post-Pay code edit/rules development is recommended/encouraged as well.
Salary Range for this role is: $120k - $125k
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Originally posted on Himalayas