DRG QA/Training Manager

🔥 0 minutes ago

🇺🇸 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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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, setting goals and coordinating audit and training activities • Provide guidance, counsel, development plans, and performance monitoring for QA/Trainer staff • Own the QA audit program for new and existing DRG Reviewers • Review audit findings, calibrate audit criteria, identify trends and root causes, and implement corrective actions • 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 and maintain training materials and resources • Develop QA policies, processes, and training standards • Maintain audit, feedback, and training documentation • Report quality scores, audit outcomes, and training effectiveness • 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 • Support research, special projects, and ad hoc claim reviews

🎯 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 • Understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems • Familiarity with Milliman and InterQual guidelines • Strong data analysis and critical judgment skills • Clear, actionable feedback and coaching ability • Experience with multiple monitors and remote working • Proficiency in Windows, Microsoft Suite, Teams, Excel, PowerPoint, and Word

🏖️ 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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