Director CERIS DRG Audit Program

Job Description

Job Description

The Director, CERIS DRG Audit Program is a strategic and operational leader responsible for the development, implementation, and oversight of all DRG clinical validation and audit initiatives. This role ensures the integrity of healthcare payments through the identification and recovery of improper payments, optimization of DRG assignments, and continuous improvement of coding accuracy, clinical documentation, and regulatory compliance.

The Director leads teams of clinical and coding auditors while collaborating across operations, policy, technology, analytics, product, sales, and client-facing functions to drive organizational performance, quality outcomes, and business growth.

ESSENTIAL FUNCTIONS & RESPONSIBILITIES:

• Develop and execute the strategic vision for the DRG Audit Program, ensuring alignment with organizational objectives, regulatory requirements, industry standards, and emerging trends
• Provide leadership and oversight for all aspects of the DRG audit lifecycle, including clinical validation, coding validation, appeals, quality assurance, operational performance, and continuous process improvement
• Establish performance goals, quality standards, key performance indicators (KPIs), and service level agreements (SLAs), utilizing data-driven insights to optimize program effectiveness, savings outcomes, and business results
• Lead, develop, and mentor teams of clinical, coding, and readmission auditors while fostering a culture of accountability, collaboration, innovation, and professional growth
• Serve as the organization's subject matter expert for DRG validation, clinical documentation, coding compliance, reimbursement methodologies, audit escalation management, and regulatory requirements
• Partner with Operations, Policy, Product, Technology, Analytics, Sales, Client Services, and other stakeholders to improve processes, support product development, drive client success, and contribute to business growth initiatives
• Provide executive-level reporting, client support, training, regulatory education, and strategic recommendations while representing the DRG Audit Program internally and externally
• Travel multiple times per year as required
• Additional duties as assigned

KNOWLEDGE & SKILLS:

• Expert knowledge of DRG validation methodologies, clinical documentation requirements, and healthcare reimbursement systems
• Extensive knowledge of MS-DRG, APR-DRG, ICD-10-CM/PCS, Medicare, and commercial payer coding and reimbursement guidelines
• Strong understanding of healthcare payment integrity, medical auditing, and regulatory compliance
• Exceptional analytical, decision-making, and problem-solving skills
• Proven ability to lead large teams, develop talent, and drive organizational performance
• Excellent written, verbal, and presentation skills with the ability to communicate effectively at all organizational levels
• Strong leadership, relationship-building, and stakeholder management skills
• Experience leveraging data, reporting, and performance metrics to drive operational improvements
• Proficiency with electronic medical record systems, audit platforms, and Microsoft Office applications
• Strong organizational and project management skills with the ability to manage multiple priorities in a fast-paced environment

EDUCATION & EXPERIENCE:

• Bachelor's degree in Health Information Management, Nursing, Healthcare Administration, or a related field, or equivalent experience required
• Master's degree preferred
• One or more of the following certifications required or strongly preferred: RHIA, RHIT, CCS, or CIC
• Additional certifications such as CCDS or other relevant clinical documentation or coding credentials preferred
• Minimum of 7-10 years of progressive experience in DRG coding, clinical validation, medical auditing, or payment integrity with a focus on inpatient DRG methodologies
• Minimum of 3-5 years of leadership experience in healthcare auditing, coding, clinical validation, or payment integrity operations
• Extensive experience with ICD-10 coding guidelines, Medicare and commercial payer regulations, and prospective payment systems
• Demonstrated success leading DRG audit programs, driving quality improvements, and delivering measurable business results
• Experience with readmission reviews preferred

PAY RANGE:

CorVel uses a market based approach to pay and our salary ranges may vary depending on your location.  Pay rates are established taking into account the following factors:  federal, state, and local minimum wage requirements, the geographic location differential, job-related skills, experience, qualifications, internal employee equity, and market conditions.  Our ranges may be modified at any time.

For leveled roles (I, II, III, Senior, Lead, etc.) new hires may be slotted into a different level, either up or down, based on assessment during interview process taking into consideration experience, qualifications, and overall fit for the role.  The level may impact the salary range and these adjustments would be clarified during the offer process.

Pay Range:  $103,640 – $161,535

A list of our benefit offerings can be found on our CorVel website: CorVel Careers | Opportunities in Risk Management

In general, our opportunities will be posted for up to 1 year from date of posting, or until we have selected candidate(s) to fulfill the opening, whichever comes first.

ABOUT CERIS:

CERIS, a division of CorVel Corporation, a certified Great Place to Work® Company, offers incremental value, experience, and a sincere dedication to our valued partners. Through our clinical expertise and cost containment solutions, we are committed to accuracy and transparency in healthcare payments. We are a stable and growing company with a strong, supportive culture along with plenty of career advancement opportunities. We embrace our core values of Accountability, Commitment, Excellence, Integrity and Teamwork (ACE-IT!). 

A comprehensive benefits package is available for full-time regular employees and includes Medical (HDHP) w/Pharmacy, Dental, Vision, Long Term Disability, Health Savings Account, Flexible Spending Account Options, Life Insurance, Accident Insurance, Critical Illness Insurance, Pre-paid Legal Insurance, Parking and Transit FSA accounts, 401K, ROTH 401K, and paid time off.

CorVel is an Equal Opportunity Employer, drug free workplace, and complies with ADA regulations as applicable.

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