Director, Pre-Bill DRG Review - Quality Assurance, Training & Education

About Us:

Our purpose is to help clients exceed their financial health goals. Across the reimbursement cycle, our scalable solutions and clinical expertise help solve programmatic needs. Enabling our teams with leading technology allows analytics to guide our solutions and keeps us accountable achieving goals.

We build long-term careers by investing in YOU. We seek to create an environment that cultivates your professional development and personal growth, as we believe your success is our success.
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:
Key Responsibilities

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 codi