Who We Are:

At the intersection of health plans and providers, Apixio is creating a leading Connected Care platform to minimize reimbursement inaccuracies and high-quality patient care so they can thrive as the industry moves toward value-based reimbursement models.

The combination brings together healthcare expertise, AI/machine learning technology and data-driven analytics solutions to deliver innovative solutions and value to our customers and the healthcare ecosystem. We aim to accelerate the shift toward alternative payment models, while enhancing efficiency and supporting better patient outcomes.

About the Role:

The DRG Manager is responsible for the development and management of our clinical solutions, including MS and APR-DRG validation. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Key responsibilities include inventory and team management, implementation support, client support, research, and management. This role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of our clinical solutions and ensure optimal team performance.

Who You Are:

Enhance and Review Clinical Solutions: Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
Collaborative Development: Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
Team Leadership: Lead the DRG team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth of DRG staff.
Claims Review Management: Oversee the entire process of clinical claims review, understanding various client configurations and workflows.
Operational Oversight: Manage scheduling, reporting to management, issue resolution, and execution of plans.
Work Coordination: Assign and prioritize work, set goals, and coordinate daily activities of the team. Provide regular updates and communication through one-on-one and team meetings.
Performance Monitoring: Monitor individual and team results to ensure timely completion of work in accordance with department standards and medical policy guidelines.
Analytical Problem-Solving: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
Policy and Process Development: Develop departmental policies, processes, and training standards.
Support and Evidence: Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
Performance Reporting: Provide reports on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory on a predetermined schedule.
Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
Program Deployment: Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
Other Duties: Perform other duties as assigned.

What You Bring to the Table:

Skills, Knowledge, Education, and Experience

Bachelor’s degree (health administration, business, nursing)
Equivalent experience of 5+ years in healthcare billing and coding
Equivalent experience of 2+ years in claims auditing and recovery auditing
Preferred coding certification and nursing license

Experience:

Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG
Preferable experience with outpatient payment systems such as APCs and EAPGs
Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
Strong experience in data utilization and insights
Experience independently structuring and executing complex analyses
Familiarity with Milliman and InterQual guidelines
Expertise in DRG validation
Experience in production and team management
Experience with Readmission reviews
Ability to work efficiently and effectively with minimal supervision
High standards of quality and attention to detail
Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
Superior knowledge of healthcare coding, billing, and reimbursement
Expert knowledge of clinical criteria documentation requirements
Subject matter expertise in DRG validation

Computer Equipment and Software:

Experience working with multiple monitors
Proven success in a remote working environment
Proficient in Windows office systems, including the full Microsoft Suite and Teams
Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
Experience with various software applications and collaboration with development teams
Familiarity with multiple encoder/grouper applications

Physical Demands:

Ability to sit or stand for long periods, with occasional stooping and reaching
May require lifting up to 25 pounds
Requires a normal range of vision and hearing, with or without accommodations
Position is not substantially exposed to adverse environmental conditions

The salary range below is for Base Salary. Total compensation also includes benefits and variable compensation. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.

Base Compensation

$80,000—$135,000 USD

We recognize that people come with experience and talent beyond just the technical requirements of a job. If your experience is close to what you see listed here, please consider applying. Diversity of experience and skills combined with passion is a key to innovation and excellence. Therefore, we encourage people from all backgrounds to apply to our positions. Your skills and background may be more translatable to this role than you initially thought. Allow us the opportunity to get to know you. Please let us know if you require accommodations during the interview process.

What Apixio can offer you:

Meaningful work to advance healthcare
Competitive compensation
Exceptional benefits, including medical, dental and vision, FSA
401k with company matching up to 4%
Generous vacation policy
Remote-first & hybrid work philosophies
A hybrid work schedule (2 days in office & 3 days work from home) (Note: If the position is designated as REMOTE it will stay REMOTE)
Modern open office in beautiful San Mateo, CA; Los Angeles, CA; San Diego, CA; Austin, TX and Dallas, TX
Subsidized gym membership
Catered, free lunches
Parties, picnics, and wine-downs
Free parking

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We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace.

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