DRG Quality Manager
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Job Description
DRG Quality Manager leading MS-DRG and APR-DRG quality reviews for EXL’s healthcare clients. Supervising analysts, ensuring coding accuracy, compliance, SLAs, and process improvement.
Responsibilities:
- Support the execution and ongoing improvement of DRG quality review programs, including readmissions and place of service reviews
- Partner with technology, operations, and training teams to implement audit quality solutions
- Oversee day-to-day quality review operations in alignment with client SLAs, quality expectations, productivity goals, and internal standards
- Manage quality review inventory, workflow distribution, QA aging, and productivity
- Directly supervise DRG quality analysts and, as needed, analysts supporting other clinical or coding quality specialties
- Provide coaching, feedback, performance management, one-on-ones, training, and development planning
- Ensure adherence to productivity, quality, accuracy, and SLA standards
- Monitor regulatory and payer guideline updates to keep reviews compliant and current
- Identify quality, operational, and process gaps and drive improvement initiatives
- Escalate and help resolve client, quality, auditor performance, and operational issues
- Support reporting on productivity, quality, audit accuracy, QA inventory, and defect trends
- Assist with program implementations by defining quality expectations, review criteria, and quality control processes
- Ensure consistency and alignment across quality analysts, programs, Operations, Training, and global partners
- Facilitate ongoing development, knowledge depth, and upskilling of quality analysts
Requirements:
- Active coding credential required, such as CCS, RHIT, RHIA, or CPC
- 5–8 years of experience with MS-DRG and APR-DRG
- Strong knowledge of ICD-10-CM/PCS and Official Coding Guidelines
- Prior experience leading teams or acting in a supervisory capacity
- Strong understanding of DRG reimbursement methodologies
- Knowledge of Medicare, Medicaid, CMS regulations, and commercial payer guidelines
- Experience in audit, payment integrity operations, healthcare quality operations, or coding quality review
- Strong analytical skills with ability to identify trends and support decision-making
- Effective communication and interpersonal skills
- Proficiency in Microsoft Office, dashboards, Excel, and audit/reporting systems
- Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred
- A brief coding/auditing assessment may be included as part of the interview process
Benefits:
- Competitive benefits package, including healthcare, vision, dental, and 401(k) options
- Fast-paced, innovative environment with a team of industry-leading experts
- Hands-on experience with top-tier clients in the healthcare industry
- Strong culture of collaboration, support, and inclusivity
- Limited travel may be required for team meetings
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