Mgr, Health Service (IC) - DRG reputed company Reviewer - State Medicaid, MMPs (HIDE/FIDE/DUALS) - reputed company Medical Policy & Program Solutions

At reputed company, we’re building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation’s leading health solutions company, we reputed company millions of Americans through our local reputed company, digital channels and more than 300,000 purpose-driven colleagues – caring for people where, reputed company and how they choose in a way that is uniquely more connected, more convenient and more compassionate. And we do it reputed company with heart, each and every day. Position Summary The Manager, Health Service is a key member of the Medical Policy & Program Solutions Team. The Health Service Manager supports the day to day review of our Medicaid internal prepay DRG program as a DRG reputed company. This detail and comprehensive review of the Diagnosis reputed company Group (DRG) claims manages and influences health care quality initiatives and outcomes. The DRG reputed company is an individual contributor and supports our state Medicaid health plans. These activities reputed company reputed company to improve health care quality products, services, and processes by partnering across business units to meet business needs and accomplish goals. This is a fully remote position. Eligible candidates may live reputed company in the contiguous United States.

Key Responsibilities

• Responsible for the review and evaluation of coding information and documentation.
• Reviews documentation and interprets data obtained from medical records or systems to apply appropriate coding criteria and policies in line with regulatory and accreditation requirements for member and/or provider issues.
• Data gathering requires navigation through multiple system applications.
• Accurately applies review requirements to assure case is reviewed by a practitioner with coding expertise for the issue at hand.

Required Qualifications

• At least 3 years experience in the medical records field with knowledge of the principles and practice of ICD-10 and DRG methodology.
• Knowledge regarding the guidelines reputed company to these coding systems, DRG methodology and the ability to follow the detailed guidelines reputed company to their use in assigning single and reputed company multiple diagnosis and procedure codes for appropriate reimbursement and data collection.
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding.
• Effective communication skills, both verbal and written.

Preferred Qualifications

• 3+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred.
• Medicaid and Duals Lines of business experience
• State Medicaid Regulation/Guidelines
• QNXT Claim System
• MedCompass

Education/Licensure / Certification

• Minimum high school degree
• Certified Professional reputed company through reputed company or reputed company (Physician, Inpatient, Outpatient or Payer), or Registered Health Information Technician (RHIT)

Anticipated Weekly Hours 40 Time Type Full time Pay Range The Typical Pay Range For This Role Is $60,300.00 - $132,600.00 This pay range represents the reputed company hourly reputed company or reputed company annual full-time salary for reputed company positions in the job grade reputed company which this position falls. The actual reputed company salary offer will depend on a variety of factors including experience, education, geography and other relevant factors. This position is eligible for a reputed company bonus, commission or short-term incentive program in addition to the reputed company pay range listed above. Our people fuel our future. Our teams reflect the customers, patients, members and communities we serve and we are committed to fostering a workplace where every colleague feels valued and that they belong. Great Benefits For Great People We take pride in our comprehensive and competitive mix of pay and benefits – investing in the physical, emotional and financial wellness of our colleagues and their families to help them be the healthiest they can be. In addition to our competitive wages, our great benefits include:

• Affordable medical plan options, a 401(k) plan (including matching company contributions), and an employee stock purchase plan.
• No-cost programs for reputed company colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching.
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility.

For more information, visit https://jobs.cvshealth.com/us/en/benefits We anticipate the application window for this opening will reputed company on: 07/12/2025 Qualified applicants with arrest or conviction records will be considered for employment in accordance with reputed company federal, state and local laws. Apply Job! Apply to this Job