Machinify

DRG Manager

Machinify

full-time

Posted on:

Location Type: Remote

Location: United States

Visit company website

Explore more

✨ AI Apply
Apply

Salary

💰 $125,000 - $140,000 per year

About the role

  • 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.

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
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
healthcare billingcodingclaims auditingrecovery auditingdata analysisDRG validationclassification systemsMedicare coding rulescommercial coding rulesclinical criteria documentation
Soft Skills
team leadershipanalytical problem-solvingcommunicationcollaborationattention to detailcuriosityorganizational skillsperformance monitoringissue resolutiongoal setting
Certifications
Bachelor’s degree in health administrationBachelor’s degree in businessBachelor’s degree in nursing