DRG QA/Training Manager
Leads the QA and training team behind Machinify's DRG Clinical Validation: manages DRG QA/trainers, owns the audit program for DRG reviewers, and directs onboarding and ongoing training on MS-DRG/APR-DRG validation, ICD-10-CM/PCS coding, and internal tools. Remote US healthcare role paying $130k-$150k plus bonus.
- Compensation
- $130K–$150K / yr
- Location
- Remote - US
- Work setup
- Remote
- Seniority
- Not specified
- Employment
- Full time
- Experience
- 3+ years
- Category
- Qa
- Posted
Skills
Must have
- Bachelor's degree in nursing, health information management, or health administration (work experience may substitute at leadership discretion)
- At least one certification: RHIA, RHIT, CCDS, CDIP, CCS, or CIC
- 5+ years of experience in healthcare billing and coding
- 3+ years of inpatient claims auditing, QA, recovery auditing, and/or inpatient CDI experience
- Previous supervisory experience
- Experience in production and team management
- Experience conducting training for clinical or coding staff
- Experience with readmission reviews
- Experience sharing DRG audit process knowledge with sales, marketing, and development teams
- Expert in DRG methodologies: MS-DRG, APR-DRG, AP-DRG
- Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA Coding Clinic
- Expertise in DRG validation with knowledge of clinical criteria and documentation requirements
- Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
- Familiarity with Milliman and InterQual guidelines
- Ability to apply critical judgment in clinical and coding determinations
- Strong data analysis skills, independently structuring and executing complex analyses
- Ability to provide clear, actionable feedback and coach staff
- High standards of quality and attention to detail
- Strong organizational and time management skills
- Excellent written and verbal communication
- Ability to work independently and collaboratively
- Experience working with multiple monitors
- Proven success working remotely
- Proficient in Windows office systems, including full Microsoft Suite and Teams
- Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
- Experience with various software applications and collaboration with development teams
Nice to have
- Active, unrestricted nursing license
Full description
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 85 health plans, including many of the top 20, and representing more than 270 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.
About the Opportunity
The DRG QA/Training Manager leads the quality assurance and training team supporting Machinify’s DRG Clinical Validation function, including MS-DRG and APR-DRG validation. Reporting to the Sr. Director, DRG Operations, this role manages the DRG QA/Trainers, owns the audit program for new and existing DRG Reviewers, and directs onboarding and ongoing training so reviewers apply current clinical, coding, and organizational standards. The manager works with the DRG Clinical Educator, DRG Managers, and cross-functional partners to turn audit findings into training, process changes, and measurable quality improvement.
What you’ll do
Team Leadership:
- Lead the DRG QA/Trainer team by setting goals, assigning and prioritizing audit and training work, and coordinating daily activities
- Provide guidance, counsel, and development plans that support long-term retention and professional growth of QA/Trainer staff
- Communicate priorities, updates, and expectations through regular one-on-one and team meetings
- Monitor individual and team results to ensure audits and training are completed on time and in accordance with department standards
Quality Assurance:
- Own the QA audit program for new and existing DRG Reviewers, ensuring accuracy, compliance, and alignment with established coding and clinical validation guidelines
- Review QA/Trainer audit findings for consistency and calibrate the team on audit criteria and feedback
- Ensure DRG Reviewers receive constructive, detailed feedback that highlights areas for improvement and recognizes high-performance results
- Identify problems and trends in audit results, determine root causes, and implement corrective action plans
- Collaborate with leadership to drive continuous improvement in audit accuracy, workflow efficiency, and reviewer performance
Training & Education:
- Partner with the educator to plan and deliver new-hire training on DRG methodologies, clinical validation, and proprietary tools