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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in DRG methodologies, clinical validation, and inpatient claims auditing, while effectively leading and training QA/Trainer teams to enhance audit accuracy and workflow efficiency. Proficient in developing QA policies and maintaining comprehensive training resources to support continuous improvement in healthcare billing and coding.
Highest-signal resume keywords
DRG Methodologies ExpertiseInpatient Claims Auditing ExperienceQuality Assurance LeadershipICD-10-CM/PCS Coding ProficiencyRHIA/RHIT/CDDS/CDIP/CCS/CIC Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
DRG ValidationClinical Documentation IntegrityHealthcare Billing and CodingAudit Program ManagementData AnalysisTraining DevelopmentPerformance MonitoringCorrective Action ImplementationTrend IdentificationRoot Cause Analysis
Soft Skills
Clear Feedback AbilityCoaching SkillsCollaborationCritical JudgmentTeam Management
Tools & Technologies
Microsoft SuiteExcelPowerPointWordTeamsWindows
Certifications & Qualifications
RHIARHITCCDSCDIPCCSCIC
Industry Keywords
Medicare Coding RulesCommercial Coding RegulationsProspective Payment SystemsMilliman GuidelinesInterQual GuidelinesUHDDS DefinitionsOfficial Coding GuidelinesAHA’s Coding Clinic Guidelines
About the role
Key responsibilities & impact- Lead the DRG QA/Trainer team, setting goals and coordinating audit and training activities
- Provide guidance, counsel, development plans, and performance monitoring for QA/Trainer staff
- Own the QA audit program for new and existing DRG Reviewers
- Review audit findings, calibrate audit criteria, identify trends and root causes, and implement corrective actions
- Drive continuous improvement in audit accuracy, workflow efficiency, and reviewer performance
- Plan and deliver new-hire training on DRG methodologies, clinical validation, and proprietary tools
- Oversee ongoing training and maintain training materials and resources
- Develop QA policies, processes, and training standards
- Maintain audit, feedback, and training documentation
- Report quality scores, audit outcomes, and training effectiveness
- Collaborate with DRG Managers, the DRG Clinical Educator, operations, product, data analytics, and technology teams
- Serve as an expert resource on complex cases and procedures
- Support research, special projects, and ad hoc claim reviews
Requirements
What you’ll need- A bachelor’s degree in nursing (active/unrestricted license), health information management, or health administration is required
- Work experience may be considered in lieu of formal education at leadership discretion
- At least one required certification: RHIA, RHIT, CCDS, CDIP, CCS, or CIC
- 5+ years of experience in healthcare billing and coding
- 3+ years of inpatient claims auditing, quality assurance, recovery auditing, and/or inpatient Clinical Documentation Integrity experience
- Previous supervisory experience required
- Experience in production and team management
- Experience conducting training for clinical or coding staff
- Experience with readmission reviews
- Proven experience sharing DRG audit process knowledge with sales, marketing, and development teams
- Expertise in DRG methodologies and classification systems, including MS-DRG, APR-DRG, and AP-DRG
- Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines
- Expertise in DRG validation, clinical criteria, and documentation requirements
- Understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
- Familiarity with Milliman and InterQual guidelines
- Strong data analysis and critical judgment skills
- Clear, actionable feedback and coaching ability
- Experience with multiple monitors and remote working
- Proficiency in Windows, Microsoft Suite, Teams, Excel, PowerPoint, and Word
Benefits
Comp & perks- Work from anywhere in the US; digital-first workplace
- Top Medical/Dental/Vision offerings
- FSA/HSA
- Tuition reimbursement
- 401(k) with company match
- Additional health and wellness benefits and perks
- Flexible and trusting environment