DRG Clinical Validation 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. 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.

Job Summary

The DRG Clinical Validation Manager is responsible for the development and management of our DRG clinical validation solutions, including MS and APR-DRG validation. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key clinical claims for review and recovery. Key responsibilities include production and team management, implementation/ integration support, KPI oversight, and providing assistance to various teams within the organization related to clinical validation.  This position also supports the leadership, operations, selection, and content development teams. 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.

Duties and Responsibilities

• Collaborative Development: Collaborate with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG CV process ideas from creation to implementation.

• Team Leadership: Lead the DRG Clinical Validation team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth while fostering a culture of accountability, innovation and clinical excellence
• Internal and External Claim Support: Support internal team members by coaching, mentoring, and providing performance feedback

• 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. Capacity planning to ensure all SLAs are met regularly.
• Clinical Guidance: Work with other clinicians and MDs to provide guidance and feedback on clinical policies, rationales, and references. Help provide feedback on clinical policy performance and suggest adjustments as necessary.

• Work Coordination: Overall management of daily queue inventory. 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.
• Quality Assurance/Improvement Oversight: Establish and maintain quality assurance standards and continuous improvement processes to ensure clinical validation accuracy and consistency.
• 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: Manage and track data on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory.
• Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology. Work with testing team to communicate and train the DRG CV team on changes rolled out in software releases.
• Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
• Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
• Other Duties: Perform other duties as assigned.

Skills, Knowledge, Education, and Experience
 

• 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
• Nursing or MD/DO license required
• Required certifications of CCS, CCDS or CDIP
• Previous 3+ years supervisory experience required

 Experience
 

• Proven experience working within a team, sharing DRG clinical validation audit process knowledge
• Experience with training or education preferred
• Proven experience with Clinical Validation
• Proven knowledge of classification systems, including MS-DRG, APR-DRG, AP-DRG
• Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
• Experience with recovery auditing preferred
• Strong experience in data utilization and insights
• Experience independently structuring and executing complex analyses
• Experience in production and team management
• Experience with Readmission and Short Stay 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 DRG clinical validation

Computer Equipment and Software
 

• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficiency 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

Physical Demands
 

• Ability to sit or stand for long periods, with occasional stooping and reaching
• May require lifting up to 25 pounds
• Requires a normal range of vision and hearing, with or without accommodation
• Position is not substantially exposed to adverse environmental conditions

This is an exempt position. The salary range is between $125,000 and $140,000 USD
 

For Salary position only: 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   
 

• 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 we’ll share with you
 

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

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 are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In 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 Machinify_Careers@machinify.com. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/