Machinify · 13 hours ago
DRG Manager
United States
Full-time
Remote
Mid, Senior Level
$125K/yr - $140K/yr
5+ years expMachinify is a leading healthcare intelligence company focused on maximizing financial outcomes and reducing healthcare costs. As a DRG Manager, you will be responsible for the development and management of clinical solutions, overseeing claims review processes, and leading a team to ensure optimal performance and compliance with industry standards.
AnalyticsArtificial Intelligence (AI)Business IntelligenceMachine LearningPredictive AnalyticsSaaS
Hiring Manager
Jon Toshiro Fuezy
Responsibilities
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
Qualification
Required
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
Top Medical/Dental/Vision offerings
FSA/HSA
Tuition reimbursement
Competitive salary, 401(k) with company match
PTO
Additional health and wellness benefits and perks
Flexible and trusting environment where you’ll feel empowered to do your best work
Company
Machinify
Machinify is a SaaS platform that enables non-technical enterprises to build AI-powered products and processes.
1001-5000 employees
H1B Sponsorship
Machinify has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (12)
2024 (6)
2023 (3)
2022 (3)
2021 (4)
2020 (5)
Funding
Current Stage
Late StageTotal Funding
$12.79MKey Investors
Battery Ventures
2025-01-10Acquired
2018-10-08Series A· $10M
2016-03-15Seed· $2.79M
Leadership Team
Edward Lichty
Strategic Operations
Prasanna Ganesan
EVP & Chief Product Officer
Recent News
2025-12-19
Dallas Morning News
2025-10-24
globallegalchronicle.com
2025-10-24
Company data provided by crunchbase