DRG Manager
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 60 health plans, including many of the top 20, and representing more than 160 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.
Location : This role is full remote
About the Opportunity
At NewCo, we're constantly reimagining what's possible in our industrycreating disruptively simple, powerfully clear ways to maximize our clients' financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions team, you will, as the DRG Manager, be responsible for the development and management of our clinical solutions, including MS and APR-DRG validation. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Key responsibilities include inventory and team management, implementation support, client support, research, and management. This role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of our clinical solutions and ensure optimal team performance.
What you'll do
What Experience You Bring (Role 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
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
What Success Looks Like
After 3 months
After 1 year
Pay range : $125,000-$140,000
This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.
What's in it for you
What values we'll share with you
At Machinify, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.
Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative and accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.
We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We
Manager • Roseville, CA, US