DRG Manager

🕒 March 12

🇺🇸 United States – Remote

💵 $125k - $140k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

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

Healthcare Insurance • Artificial Intelligence • SaaS

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

• Enhance and Review Clinical Solutions: Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions. • Collaborative Development: Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation. • Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes. • Team Leadership: Lead the DRG team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth of DRG staff. • Claims Review Management: Oversee the entire process of clinical claims review, understanding various client configurations and workflows. • Operational Oversight: Manage scheduling, reporting to management, issue resolution, and execution of plans. • Work Coordination: Assign and prioritize work, set goals, and coordinate daily activities of the team. Provide regular updates and communication through one-on-one and team meetings. • Performance Monitoring: Monitor individual and team results to ensure timely completion of work in accordance with department standards and medical policy guidelines. • Analytical Problem-Solving: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans. • Policy and Process Development: Develop departmental policies, processes, and training standards. • Support and Evidence: Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances. • Performance Reporting: Provide reports on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory on a predetermined schedule. • Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology. • Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies. • Program Deployment: Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes. • Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed. • Other Duties: Perform other duties as assigned.

🎯 Requirements

• Bachelor’s degree (health administration, business, nursing) • Equivalent experience of 5+ years in healthcare billing and coding • Equivalent experience of 3+ years in claims auditing and recovery auditing • Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams • Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs • Demonstrated curiosity and mastery in understanding the root cause of events and behaviors • Strong experience in data utilization and insights • Experience independently structuring and executing complex analyses • Familiarity with Milliman and InterQual guidelines • Expertise in DRG validation • Experience in production and team management • Experience with Readmission reviews • Ability to work efficiently and effectively with minimal supervision • High standards of quality and attention to detail • Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems • Superior knowledge of healthcare coding, billing, and reimbursement • Expert knowledge of clinical criteria documentation requirements • Subject matter expertise in APR-DRG validation, Readmissions, and Place of Service

🏖️ Benefits

• Work from anywhere in the US! Machinify is digital-first. • Top Medical/Dental/Vision offerings • FSA/HSA • Tuition reimbursement • Competitive salary, 401(k) with company match • Unlimited PTO • Additional health and wellness benefits and perks • Flexible and trusting environment where you’ll feel empowered to do your best work