DRG Manager

Job not on LinkedIn

October 24

🏄 California – Remote

Although this job is listed in California, this company may be open to hiring remote in other states.

💵 $125k - $140k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

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Machinify, Inc.

WebsiteLinkedInAll Job Openings

Artificial Intelligence • Healthcare Insurance • Fintech

Machinify, Inc. is a company specializing in artificial intelligence solutions for the healthcare industry, particularly in optimizing payment processes and enhancing payment integrity. Their product suite, including Machinify Audit and Machinify Pay, is designed to automate and improve the accuracy of medical claims review, identifying billing and coding errors, and reducing administrative costs. Machinify's AI-driven platform covers millions of healthcare members and delivers significant financial benefits by efficiently processing medical claims and empowering health plans to tailor their policies. With a focus on transparency, control, and safety in AI, Machinify offers customized solutions that adapt to the specific needs of healthcare providers and contribute to the transformation of healthcare payments.

51 - 200 employees

🤖 Artificial Intelligence

⚕️ Healthcare Insurance

💳 Fintech

💰 $10M Series A on 2018-10

📋 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 • Computer Equipment and Software: Experience working with multiple monitors • Proven success in a remote working environment • Proficient in Windows office systems, including the full Microsoft Suite and Teams • Advanced skills in Microsoft Office (Excel, PowerPoint, Word) • Experience with various software applications and collaboration with development teams • Familiarity with multiple encoder/grouper applications

🏖️ Benefits

• PTO • Paid Holidays • Volunteer Days • Eligibility for health, vision and dental coverage • 401(k) plan participation with company match • Flexible spending accounts • Tuition Reimbursement • Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave. • Remote and hybrid work options