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JOB SUMMARY:

The Director of Pre-Bill DRG Review — Quality Assurance, Training & Education leads the organization's internal pre-bill DRG (Diagnosis-Related Group) validation program, ensuring coding accuracy, DRG integrity, and compliance prior to claim submission. This role is responsible for designing, implementing, and continuously improving the quality assurance framework that governs pre-bill coding review, as well as building and leading the training and education infrastructure that supports coding staff, clinical documentation integrity (CDI) specialists, and auditors. The Director partners closely with HIM leadership, CDI, Compliance, Revenue Cycle, and Physician Advisors to reduce DRG mismatches, denials, and revenue leakage while maintaining strict adherence to Official Coding Guidelines, CMS regulations, and payer-specific requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Note: The essential duties and responsibilities below are intended to describe the general duties and responsibilities of this position and are not intended to be an exhaustive statement of duties. This position may perform all or most of the primary duties listed below. Specific tasks, responsibilities or competencies may be documented in the Team Member’s performance objectives as outlined by the Team Member’s immediate Leadership Team Member.

Essential Functions:

Note: The essential duties and primary accountabilities below are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Incumbents may perform all or most of the primary accountabilities listed below. Specific tasks, responsibilities or competencies may be documented in the incumbent’s performance objectives as outlined by the incumbent’s immediate supervisor or manager. Major responsibilities include, but are not limited:

Program Leadership & Quality Assurance

• Own and continuously evolve the pre-bill DRG review program, including scope, workflows, escalation paths, and case selection methodology (e.g., high-dollar accounts, complex MS-DRG/APR-DRG cases, high-risk service lines).
• Establish and maintain a robust quality assurance (QA) framework for coding and DRG validation, including inter-rater reliability audits, accuracy scorecards, and root-cause analysis of discrepancies.
• Set and monitor performance benchmarks (e.g., coding accuracy rate, DRG change rate, query response rate, turnaround time) and report trends to senior leadership.
• Lead second-level review and adjudication of complex or disputed DRG assignments, ensuring appropriate resolution prior to bill drop.
• Ensure the pre-bill review program aligns with Official Coding Guidelines, AHA Coding Clinic guidance, CMS regulations, and payer contract requirements.
• Identify systemic coding, documentation, or workflow issues surfaced through QA findings and translate them into targeted process or education interventions.
• Partner with Compliance and Internal Audit to ensure the program supports organizational compliance and risk-mitigation objectives.

Training & Education

• Design, implement, and maintain a structured training and competency program for coders, auditors, and CDI staff involved in pre-bill DRG review.
• Develop onboarding curricula, ongoing education modules, and remediation plans based on individual and team-level QA findings.
• Deliver or oversee delivery of education on coding guideline updates, DRG methodology changes (MS-DRG/APR-DRG), regulatory updates, and payer policy changes.
• Create and maintain reference materials, job aids, tip sheets, and a knowledge repository to support consistent, high-quality coding practice.
• Track staff competency, certification maintenance, and continuing education compliance across the coding and review team.
• Facilitate case conferences and calibration sessions to align coder, CDI, and physician advisor interpretation of complex clinical scenarios.

Cross-Functional Collaboration

• Partner with CDI leadership to reduce DRG mismatches between initial CDI working DRG and final coded DRG, and to strengthen concurrent documentation practices.
• Collaborate with Physician Advisors and Medical Staff to resolve clinical documentation ambiguity affecting DRG assignment.
• Work with Revenue Cycle and Patient Financial Services to minimize billing delays introduced by the pre-bill review process while protecting accuracy.
• Serve as a subject matter expert and liaison to external auditors, payers, and regulatory bodies regarding pre-bill DRG review methodology.

Team Leadership & Operations

• Hire, develop, coach, and manage a team of DRG validators, quality auditors, and/or training specialists.
• Establish productivity and quality standards for the pre-bill review team; conduct regular performance evaluations.
• Manage program budget, staffing models, and technology needs (e.g., encoder tools, computer-assisted coding, analytics dashboards).
• Prepare and present regular reporting on program performance, financial impact, and risk trends to senior HIM, Revenue Cycle, and Compliance leadership.

QUALIFICATIONS & REQUIREMENTS:

Education

• Bachelor's degree in Health Information Management, Nursing, Health Administration, or related field required.
• Master's degree preferred.

Certification

• RHIA, RHIT, CCS, or CDIP required (one or more).
• CCDS or CCS-P a plus.
• Active, unencumbered credential required; must be maintained throughout employment.

Experience

• 7+ years of progressive experience in inpatient coding, DRG validation, clinical documentation integrity, or coding quality/compliance auditing.
• 3+ years of leadership or management experience, including oversight of quality assurance and/or training functions.
• Demonstrated expertise in MS-DRG and APR-DRG methodology, ICD-10-CM/PCS coding, and CMS regulatory requirements.
• Experience designing and delivering adult education/training programs in a healthcare coding or clinical setting.
• Prior experience with pre-bill review, second-level review, or denials/appeals management strongly preferred.

Knowledge, Skills & Abilities

• Deep working knowledge of Official Coding Guidelines, AHA Coding Clinic, CMS Inpatient Prospective Payment System (IPPS) rules, and payer-specific DRG requirements.
• Strong analytical skills with the ability to interpret coding quality data, identify trends, and drive performance improvement.
• Excellent verbal and written communication skills, with the ability to translate complex coding concepts into clear, actionable education.
• Proven ability to build curriculum and training programs from the ground up.
• Skilled in change management and cross-functional influence without direct authority.
• Proficiency with encoder software, computer-assisted coding (CAC) tools, and coding/DRG analytics platforms.
• High degree of integrity, discretion, and sound judgment in handling sensitive compliance matters.

This role is performed in a standard office/clinical administrative environment. Some travel between facilities may be required depending on organizational structure. Occasional extended hours may be needed to meet reporting deadlines or respond to urgent compliance matters.

We Offer:

• Competitive salary commensurate to related experience
• Quality of life with a remote predictable, full-time schedule
• Medical, Dental, Vision coverage + more
• 401K with company match
• Long-term disability insurance, and life insurance
• Ample parental leave
• Certification and Tuition Reimbursement
• Holidays and Flexible paid time off

PHYSICAL DEMANDS:
Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.
A job description is only intended as a guideline and is only part of the Team Member’s function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.