Supervisor, Diagnosis-Related Group Reviews (Finance)

We offer remote work opportunities (AK, AR, AZ, CA, *CO, FL, *HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, *WA, WI & WY only).

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Supervises Diagnosis-Related Group (DRG) validation process and coding staff to ensure contractual compliance. Reports to the Manager, Retrospective UM. Supervises staff who conduct retrospective review of medical claims for appropriate DRG or non-DR coding and processing. Performs independent research and in-depth evaluation of complex medical claims. Ensures that provider documentation conforms to legal and procedural requirements. Represents TriWest as DRG coding Subject Matter Expert on work groups. The Supervisor also oversees the UM specialist staff functions, including requesting, receiving, processing, filing, and maintaining all medical records required for review. Determines work assignments, audits accuracy of work products, and is responsible for the timeliness of work completion for all assigned staff. Responsible for ensuring accuracy and currency of area related policies and procedures.

Education & Experience

Required:

• Bachelor's degree or equivalent combination of education and experience Current Certification as: Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) or Certified Coding Specialist (CCS) or Certified Professional Coder (CPC)
• 2+ years of clinical experience
• 2+ years coding experience
• 2+ years processing medical claims
• 2+ years of UM experience utilizing commercially developed UM criteria
• 2+ years supervisory/management experience

Preferred:

• Managed Care experience
• Familiarity with TRICARE and military health care delivery system

Key Responsibilities

• Supervises retrospective coding validation reviews of medical claims and associated reporting processes.
• Supervises staff processes for requesting, obtaining, filing, and managing medical records.
• Utilizes management reports to support DRG validation and medical record processes.
• Coordinates coding matrix validation, program sets, profile structure and maintenance, and routine updates for coding and policy changes due to profiles.
• Assists staff with the application of complex coding conventions to appropriately code and sequence medical claims for claims payment and DRG validation purposes.
• Stays current with updated coding information and changes in coding regulations and practices.
• Serves as Subject Matter Expert for coding issues, including implementation of new codes.
• Develops materials and trains assigned staff on coding guidelines, compliance issues, and coding policy changes, medical record process changes as appropriate.
• Coaches/mentors staff on performance standards, employee issues and concerns.

• Interprets relevant sections of the TRICARE Operations Manual, TRICARE Policy Manual, and TRICARE
• Reimbursement Manual to perform functions.
• Performs focused audits to ensure compliance with coding requirements and medical record maintenance and confidentiality.
• Interacts with internal and external entities on resolving customer services issues to ensure customer service needs are met.
• Other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Empathy / Customer Service: Customer-focused behavior; helping approach, including listening skills, patience, respect, and empathy for another's position.

Leadership: Successfully manage different styles of employees; provide clear direction and effective coaching.

Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems, within time constraints and with available resources; detail-oriented.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment.

Technical Skills: Proficient with Microsoft Word, Excel, PowerPoint, Outlook, Visio & Access; Knowledge of managed care principles and methods; Knowledge of auditing and analysis principles; Knowledge in the application of ICD-10-CM, DSM, CPT, and HCPCs and American Dental codes; Working knowledge of medical management system, including report compilation; Knowledge in health information management (HIMs) processes and retention requirements.

Working Conditions

• Availability to work any shift
• Works remotely, with up to 10% travel
• Ability to meet mandatory contract compliance timelines
• Extensive computer work with prolonged sitting

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Generous paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

*Annual base salary for Colorado, Hawaii, Washington D.C. and Washington State residents: $82,000 - $91,000 depending on experience*

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that cultivates and supports diversity at every organizational level, including hiring and retaining a diverse workforce, and we highly encourages candidates from all backgrounds to apply. Applicants are considered for positions without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.