Quality Assurance Supervisor, Utilization Management

• Supervises all daily activities of the DRG Clinical Auditors
• Demonstrated knowledge of, ICD-10-CM and PCS codes, and DRG coding, understanding of payer rules and regulations, including Medicare and Medicaid with the ability to work independently with minimal supervision and demonstrate initiative
• Required to complete DRG audits as needed
• Responsible for the overall integrity of the quality of diagnosis and procedure codes verified by the clinical review nurses, for inpatient records and documentation received with the accompanied claim
• The ideal Clinical Audit Supervisor candidate will have strong oral and written communication skills, clinical knowledge of disease process, and knowledge of medical necessity rules
• Experience with claims denials and appeals
• Responsible for holding the DRG Clinical Auditors to the quota and error/accuracy rate
• Working knowledge of HIPAA Privacy and Security Rules
• Ability to multi-task. Assist with team coverage and provide support when needed
• Ability to build relationships both internally and externally
• Demonstrated proficiency in basic computer skills and typing, i.e., Microsoft Windows, Outlook, Word, PowerPoint, Internet Explorer, etc.

• Extreme attention to detail
• Must possess problem solving, critical thinking skills
• Minimal typing experience
• Effective and professional communication skills, both verbal and written
• Ability to think and work independently, while working in an overall team environment
• Ability to work in a fast paced/production environment
• Proficient in Microsoft Office Suite

• N./L.V.N. preferred
• CCS or CIC required with DRG auditing experience in ICD-10-CM, ICD-10 PCS
• Proficient in Medicare, CMS guidelines and ICD-10 coding guidelines
• Minimum of 3-5 years of inpatient/DRG auditing experience in a hospital setting and/or payer setting
• A minimum of 2 years of supervisory experience dealing with clinical auditors is required

CorVel