DRG Manager

Who we Are

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. Were constantly reimagining whats 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 were constantly reimagining whats 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 youll do

• 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.

• Bachelors 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
  

What Success Looks Like

After 3 months

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• Youve gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

• You have mastered the tasks and responsibilities of the position executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• Youve been entrusted with greater responsibility indicating the companys confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $125000-$140000

This is an exempt position. The salary range is for Base will be determined based on several factors including but not limited to skill set years of experience and the employees geographic location.

Whats in it for you

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

What values well share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results

At Machinify were 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 were 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 are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable accordance with applicable state laws we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process please contact our People Operations team at. See our Candidate Privacy Notice at: Experience:

Manager