DRG QA/Training Manager

🕒 October 30

🇺🇸 United States – Remote

💵 $130k - $150k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📚 Learning and Development

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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• Open for 14 days.
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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 $10M Series A - Machinify on 2018-10

Healthcare • Consulting • Logistics

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Lead the DRG QA/Trainer team by setting goals, assigning and prioritizing audit and training work, and coordinating daily activities • Provide guidance, counsel, and development plans for QA/Trainer staff • Communicate priorities, updates, and expectations through one-on-one and team meetings • Monitor individual and team results to ensure timely, standards-compliant audits and training • Own the QA audit program for new and existing DRG Reviewers • Review audit findings, calibrate audit criteria and feedback, and ensure constructive reviewer feedback • Identify audit problems and trends, determine root causes, and implement corrective action plans • Drive continuous improvement in audit accuracy, workflow efficiency, and reviewer performance • Plan and deliver new-hire training on DRG methodologies, clinical validation, and proprietary tools • Oversee ongoing training, policy updates, skill development, and performance enhancement • Develop and maintain training materials and resources based on audit trends • Evaluate training effectiveness and adjust content based on quality results • Develop departmental QA policies, processes, and training standards • Maintain documentation of audit findings, feedback sessions, and training activities • Report KPIs including quality scores, audit outcomes, and training effectiveness • Set timelines, communicate progress, track delivery, and escalate roadblocks or dependencies • Collaborate with DRG Managers, the DRG Clinical Educator, operations, product, data analytics, and technology teams • Serve as an expert resource on complex cases and procedures • Provide partners with evidence and references supporting industry standards, auditing guidelines, and review stances • Assist with research, special projects, ad hoc claim reviews, and other assigned duties

🎯 Requirements

• A bachelor’s degree in nursing (active/unrestricted license), health information management, or health administration is required • Work experience may be considered in lieu of formal education at leadership discretion • At least one required certification: RHIA, RHIT, CCDS, CDIP, CCS, or CIC • 5+ years of experience in healthcare billing and coding • 3+ years of inpatient claims auditing, quality assurance, recovery auditing, and/or inpatient Clinical Documentation Integrity experience • Previous supervisory experience required • Experience in production and team management • Experience conducting training for clinical or coding staff • Experience with readmission reviews • Proven experience sharing DRG audit process knowledge with sales, marketing, and development teams • Expertise in DRG methodologies and classification systems, including MS-DRG, APR-DRG, and AP-DRG • Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines • Expertise in DRG validation, clinical criteria, and documentation requirements • Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems • Familiarity with Milliman and InterQual guidelines • Proven ability to apply critical judgment in clinical and coding determinations • Strong data use and insights experience, including independently structuring and executing complex analyses • Ability to provide clear, actionable feedback and coach staff to improved performance • High standards of quality and attention to detail • Strong organizational and time management skills • Excellent written and verbal communication • Ability to work independently with minimal supervision and collaboratively in teams • Experience working with multiple monitors • Proven success in a remote working environment • Proficient in Windows office systems, the full Microsoft Suite, and Teams • Advanced Microsoft Office skills in Excel, PowerPoint, and Word • Experience with various software applications and collaboration with development teams

🏖️ Benefits

• Work from anywhere in the US; digital-first workplace • Top Medical/Dental/Vision offerings • FSA/HSA • Tuition reimbursement • 401(k) with company match • Additional health and wellness benefits and perks • Flexible and trusting environment

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