DRG Manager

🕒 March 12

🇺🇸 United States – Remote

💵 $125k - $140k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👔 Manager

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 45%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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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

• Develop and manage clinical solutions, including MS and APR-DRG validation • Enhance and review readmissions, place of service, and other clinical solutions • Work with programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation • Monitor regulatory updates and adjust written rules as needed • Lead the DRG team through guidance, counsel, and development plans • Oversee the clinical claims review process across client configurations and workflows • Manage scheduling, reporting, issue resolution, and execution of plans • Assign and prioritize work, set goals, and coordinate daily team activities • Monitor individual and team results for timely completion under department standards and medical policy guidelines • Identify problems and trends, develop solutions, and implement action plans • Develop departmental policies, processes, and training standards • Provide evidence and references supporting industry standards, auditing guidelines, and review stances • Report KPIs including quality scores, workflows, savings, revenue projections, and inventory • Collaborate on solution development with operations, product, data analytics, and technology • Set timelines, track delivery, communicate progress, and escalate roadblocks or dependencies • Design and deploy programs to identify and correct claims with aberrant results • Assist with research, special projects, and ad hoc claim reviews • 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 • Meaningful equity • Annual bonus