The DRG Quality Manager leads the planning, coordination, and execution of DRG quality review activities, ensuring quality teams meet productivity goals, inventory expectations, client SLAs, and internal quality standards. This role oversees inventory, QA aging, risks, and day-to-day quality performance, while collaborating cross-functionally to support program success.
Key Skills for This Role
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Responsibilities
Support the execution and ongoing improvement of DRG quality review programs, including readmissions and place of service reviews.
Partner with cross-functional teams, including technology, operations, and training, to support implementation of audit quality solutions.
Oversee day-to-day quality review operations, ensuring alignment with client SLAs, quality expectations, productivity goals, and internal standards.
Manage quality review inventory, workflow distribution, QA aging, and productivity to ensure timely completion of quality reviews.
Provide direct supervision to DRG quality analysts and, as needed, quality analysts supporting other clinical or coding quality specialties, through coaching, feedback, and performance management.
Ensure adherence to productivity, quality, accuracy, and SLA standards.
Monitor regulatory and payer guideline updates, ensuring quality reviews remain compliant and current.
Support performance management processes, including one-on-ones, training, and development planning.
Identify quality, operational, and process gaps and drive improvement initiatives.
Escalate and help resolve client, quality, auditor performance, or operational issues as needed.
Support reporting activities, including productivity, quality, audit accuracy, QA inventory, and defect trend metrics.
Assist with program implementations and operational initiatives by defining quality expectations, review criteria, and quality control processes.
Ensure consistency and alignment across quality analysts, programs, Operations, Training, and global partners.
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The DRG Auditor is responsible for performing an in-depth review of select inpatient medical records to ensure that the assigned codes and DRG are supported by clinical documentation and all diagnoses and procedures are
Facilitate ongoing development, knowledge depth, and upskilling of quality analysts.
Support the execution and ongoing improvement of DRG quality review programs, including readmissions and place of service reviews. Partner with cross-functional teams, including technology, operations, and training, to support implementation of audit quality solutions. Oversee day-to-day quality review operations, ensuring alignment with client SLAs, quality expectations, productivity goals, and internal standards. Manage quality review inventory, workflow distribution, QA aging, and productivity to ensure timely completion of quality reviews. Provide direct supervision to DRG quality analysts and, as needed, quality analysts supporting other clinical or coding quality specialties, through coaching, feedback, and performance management. Ensure adherence to productivity, quality, accuracy, and SLA standards. Monitor regulatory and payer guideline updates, ensuring quality reviews remain compliant and current. Support performance management processes, including one-on-ones, training, and development planning. Identify quality, operational, and process gaps and drive improvement initiatives. Escalate and help resolve client, quality, auditor performance, or operational issues as needed. Support reporting activities, including productivity, quality, audit accuracy, QA inventory, and defect trend metrics. Assist with program implementations and operational initiatives by defining quality expectations, review criteria, and quality control processes. Ensure consistency and alignment across quality analysts, programs, Operations, Training, and global partners. Facilitate ongoing development, knowledge depth, and upskilling of quality analysts.
Qualifications
Experience
Active coding credential required, such as CCS, RHIT, RHIA, or CPC.
5–8 years of experience with MS-DRG and APR-DRG, including strong knowledge of ICD-10-CM/PCS and Official Coding Guidelines.
Prior experience leading teams or acting in a supervisory capacity, preferably overseeing DRG quality analysts or quality teams supporting clinical or coding specialties.
Strong understanding of DRG reimbursement methodologies.
Knowledge of Medicare, Medicaid, CMS regulations, and commercial payer guidelines.
Experience working in audit, payment integrity operations, healthcare quality operations, or coding quality review.
Strong analytical skills with ability to identify trends and support decision-making.
Effective communication and interpersonal skills.
Proficiency in Microsoft Office and audit/reporting systems.
Skills & Competencies
Strong analytical skills with the ability to identify trends, evaluate quality and audit performance, and support decision-making.
DRG expertise, including the ability to evaluate audit trends, identify coding or clinical documentation gaps, and translate findings into coaching, calibration, and process improvement actions.
Ability to manage quality review workflows, team capacity, review inventory, productivity, calibration, and performance to meet quality and SLA targets.
Strong attention to consistency, accuracy, and detail in quality review outcomes.
Results-oriented approach with the ability to manage multiple priorities and projects under pressure.
Excellent interpersonal skills with the ability to build positive relationships with coworkers, team members, clients, and stakeholders.
Excellent verbal, written, and presentation communication skills.
Ability to adapt to change and support evolving program, client, and operational needs.
Proficiency with Microsoft Office, dashboards, Excel, and audit/reporting systems.
Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred.
Key Success Indicators
High-quality, accurate, timely, and consistent quality review results across DRG and assigned programs, including correct DRG validation, clinical support, coding guideline application, and audit rationale quality.
Strong trend analysis, identification of improvement opportunities, and implementation of solutions.
Team development and depth of knowledge maintained and enhanced.
Alignment of quality processes across programs and global teams.
Achievement of quality KPIs, SLA expectations, calibration standards, and client satisfaction metrics.
Operational efficiencies and scalable processes implemented successfully.
What We Offer
A fast-paced, innovative environment with a team of industry-leading experts.
Hands-on experience with top-tier clients in the healthcare industry.
A strong culture of collaboration, support, and inclusivity.
Competitive benefits package, including healthcare, vision, dental, and 401(k) options.
The posted base salary range is the hiring base salary range for this role. Final offers are based on several factors, including: the candidate's skills and experience, internal pay equity, work location, market conditions for the role, and the specific scope and responsibilities of the position.
Experience Active coding credential required, such as CCS, RHIT, RHIA, or CPC. 5–8 years of experience with MS-DRG and APR-DRG, including strong knowledge of ICD-10-CM/PCS and Official Coding Guidelines. Prior experience leading teams or acting in a supervisory capacity, preferably overseeing DRG quality analysts or quality teams supporting clinical or coding specialties. Strong understanding of DRG reimbursement methodologies. Knowledge of Medicare, Medicaid, CMS regulations, and commercial payer guidelines. Experience working in audit, payment integrity operations, healthcare quality operations, or coding quality review. Strong analytical skills with ability to identify trends and support decision-making. Effective communication and interpersonal skills. Proficiency in Microsoft Office and audit/reporting systems. Skills & Competencies Strong analytical skills with the ability to identify trends, evaluate quality and audit performance, and support decision-making. DRG expertise, including the ability to evaluate audit trends, identify coding or clinical documentation gaps, and translate findings into coaching, calibration, and process improvement actions. Ability to manage quality review workflows, team capacity, review inventory, productivity, calibration, and performance to meet quality and SLA targets. Strong attention to consistency, accuracy, and detail in quality review outcomes. Results-oriented approach with the ability to manage multiple priorities and projects under pressure. Excellent interpersonal skills with the ability to build positive relationships with coworkers, team members, clients, and stakeholders. Excellent verbal, written, and presentation communication skills. Ability to adapt to change and support evolving program, client, and operational needs. Proficiency with Microsoft Office, dashboards, Excel, and audit/reporting systems. Knowledge of process improvement methodologies, including Lean, Six Sigma, or equivalent, preferred. Key Success Indicators High-quality, accurate, timely, and consistent quality review results across DRG and assigned programs, including correct DRG validation, clinical support, coding guideline application, and audit rationale quality. Strong trend analysis, identification of improvement opportunities, and implementation of solutions. Team development and depth of knowledge maintained and enhanced. Alignment of quality processes across programs and global teams. Achievement of quality KPIs, SLA expectations, calibration standards, and client satisfaction metrics. Operational efficiencies and scalable processes implemented successfully. What We Offer A fast-paced, innovative environment with a team of industry-leading experts. Hands-on experience with top-tier clients in the healthcare industry. A strong culture of collaboration, support, and inclusivity. Competitive benefits package, including healthcare, vision, dental, and 401(k) options.
About EXL
Professional Services10,001+Founded 1999
EXL is a global data and AI company that provides analytics, digital operations, and industry-specific services to enterprises in insurance, healthcare, banking, retail, media, and energy.
