Director, Pre-bill DRG Validation Program

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 will develop and implement CDI strategies, policies, and workflows to optimize documentation processes and improve clinical outcomes and data integrity. Key responsibilities include growing the business and defining the market strategy as well as overseeing a team of CDI professionals and ensuring high-quality service delivery supporting multiple clients and systems. The Director plays a critical role in supporting client relationships, performance reporting, and the growth of CDI service lines.

This is a remote position that may require up to 30% travel.

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.

Position Summary

CorroHealth is seeking an accomplished clinical and coding leader to serve as Director of the Pre-bill DRG Validation Program. This role owns the strategy, operations, quality, and financial performance of CorroHealth's pre-bill DRG validation service line, which reviews inpatient encounters prior to claim submission to ensure that assigned MS-DRGs and APR-DRGs are fully supported by clinical documentation, accurately coded, and compliant with CMS, Official Coding Guidelines, and payer requirements.

The Director leads a multidisciplinary team of clinical validation reviewers, coding auditors, and CDI specialists; partners with client hospital and health system leadership; and is accountable for program outcomes including accuracy rates, turnaround times, denial prevention, and net revenue impact.

Key Responsibilities

Program Leadership and Strategy

• Own end-to-end design, execution, and continuous improvement of the pre-bill DRG validation program across all assigned client engagements.
• Establish program goals, key performance indicators, and service-level commitments; report performance to executive leadership and clients.
• Develop and maintain review methodologies, case selection logic, and prioritization criteria that maximize financial and compliance impact.
• Identify opportunities to expand service offerings and support business development through subject-matter expertise, proposal input, and client presentations.

Clinical and Coding Oversight

• Serve as the senior clinical and coding authority for DRG validation, clinical validation, and query practice within the program.
• Ensure all reviews are conducted in accordance with ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, CMS regulations, ACDIS/AHIMA query practice guidelines, and applicable payer policies.
• Adjudicate escalated and complex cases, including clinical validation disputes, conflicting documentation, and high-dollar DRG shifts.
• Maintain a formal quality assurance program with inter-rater reliability targets, second-level review, and documented corrective action.

Team Management

• Recruit, onboard, develop, and retain a high-performing team of clinical validators, DRG auditors, and CDI professionals, including team leaders and supervisors.
• Set productivity and quality expectations; conduct performance evaluations; manage coaching, development plans, and corrective action.
• Design and deliver ongoing education on regulatory changes, coding updates, and emerging clinical validation topics.
• Manage staffing models, capacity planning, and workload distribution to meet client volume and turnaround requirements.

Client Relationship Management

• Act as executive point of contact for client HIM, CDI, Compliance, and Revenue Cycle leadership on program matters.
• Lead client governance meetings, present outcomes and trend analyses, and translate findings into actionable documentation and coding improvement recommendations.
• Resolve client escalations and manage program changes, scope adjustments, and issue remediation.

Compliance, Data, and Operations

• Ensure program practices comply with HIPAA, OIG guidance, and CorroHealth compliance policies; support internal and external audits.
• Partner with Analytics to develop dashboards and reporting on DRG change rates, financial impact, query response rates, denial trends, and reviewer performance.
• Collaborate with Technology and Product teams on workflow tooling, case routing, and automation opportunities.
• Manage program budget, including labor costs, vendor relationships, and profitability targets.

Required Qualifications

Education

• Clinical degree required: Registered Nurse (BSN or ADN with active licensure), Doctor of Medicine (MD/DO), Physician Assistant, Nurse Practitioner, or equivalent clinical credential from an accredited institution.
• Bachelor's degree required; Master's degree (MSN, MHA, MBA, or related) preferred.

Certifications (all required)

• Coding certification: CCS (AHIMA) Preferred
• CDI certification: CCDS (ACDIS) or CDIP (AHIMA) required.

Experience

• Minimum ten (5) years of hands-on experience performing and/or overseeing DRG validation reviews, including MS-DRG and APR-DRG methodologies, clinical validation, and pre-bill review workflows.
• Minimum five (3) years of people management experience leading clinical, coding, or CDI teams, including direct supervision of managers or team leads.
• Demonstrated experience managing programs in a hospital, health system, payer, or healthcare consulting/outsourcing environment.
• Proven track record of delivering measurable financial and quality outcomes through DRG validation or CDI programs.

Knowledge, Skills, and Abilities

• Expert command of ICD-10-CM/PCS, MS-DRG and APR-DRG grouping logic, CC/MCC capture, SOI/ROM, and Coding Clinic guidance.
• Deep understanding of compliant query practice, clinical validation standards, and payer denial and appeal processes.
• Strong analytical skills with the ability to interpret program data and present findings to executive and clinical audiences.
• Executive presence, exceptional written and verbal communication, and the ability to influence physicians, HIM, and finance leaders.
• Proficiency with encoders, CDI platforms, and EHR systems (e.g., 3M/Solventum, Epic, Cerner/Oracle Health).

Preferred Qualifications

• Experience in a multi-client outsourced services or consulting environment.
• Prior experience building or scaling a pre-bill or concurrent review program from inception.
• Experience with pediatric, academic medical center, or specialty inpatient populations.
• Familiarity with AI-assisted coding or CDI technologies and their governance.
• Six Sigma, Lean, or PMP certification.

Working Conditions

• Remote position with an estimated 15-25% travel for client meetings, on-site assessments, and company events.
• Standard business hours with flexibility required to support client time zones and deadlines.
• Extended periods of computer-based work.

Compensation and Benefits

• Competitive base salary commensurate with experience, plus annual performance-based bonus.
• Comprehensive medical, dental, and vision coverage; 401(k) with company match; paid time off and holidays; continuing education and certification maintenance support.

CorroHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

This is a remote position.

PHYSICAL DEMANDS:

Note: Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions as described. Regular eye-hand coordination and manual dexterity is required to operate office equipment. The ability to perform work at a computer terminal for 6-8 hours a day and function in an environment with constant interruptions is required. At times, Team Members are subject to sitting for prolonged periods. Infrequently, Team Member must be able to lift and move material weighing up to 20 lbs. Team Member may experience elevated levels of stress during periods of increased activity and with work entailing multiple deadlines.

A job description is only intended as a guideline and is only part of the Team Member's function. The company has reviewed this job description to ensure that the essential functions and basic duties have been included. It is not intended to be construed as an exhaustive list of all functions, responsibilities, skills and abilities. Additional functions and requirements may be assigned by supervisors as deemed appropriate.