DRG QA/Training Manager

Machinify; Oregon; Hybrid; USD 130,000 - 150,000; Full time

Benefits offered by this job

Top Medical/Dental/Vision offerings

401(k) with company match

Tuition reimbursement

Flexible and empowering environment

Job summary

Machinify is seeking a DRG QA/Training Manager to lead the QA/Trainer team, own the audit program, and drive training aligned with coding and clinical validation guidelines.

You will partner with DRG Managers and the Educator to implement continuous improvements, develop training materials, and provide actionable feedback. This role supports a remote-working environment targeting healthcare payer clients.

Qualifications

• 5+ years of experience in healthcare billing and coding
• 3+ years of inpatient claims auditing, QA, or recovery auditing
• Previous supervisory experience required
• Experience with readmission reviews
• Proven ability to share DRG audit process knowledge with cross-functional teams

Responsibilities

• Lead the DRG QA/Trainer team, set goals, prioritize audit and training work
• Own the QA audit program for DRG Reviewers and ensure accuracy and compliance
• Oversee training for DRG methodologies and proprietary tools
• Develop QA policies, processes and training standards
• Collaborate with DRG Managers, Educator, and cross-functional partners on process improvements

Skills

DRG methodologies

MS-DRG

APR-DRG

AP-DRG

ICD-10-CM/PCS coding

Quality assurance

Training & coaching

Data analysis

Remote work experience

Communication

Education

Bachelor's in nursing

Health information management

Health administration

Tools

Microsoft Office (Excel, PowerPoint, Word)

Teams

Job 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

  Oversee ongoing training for existing staff, focusing on policy updates, skill development, and performance enhancement

  Direct the development and maintenance of training materials and resources, using audit trends to target content where it is needed

  Evaluate the effectiveness of training sessions and adjust content based on quality results

• Policy, Documentation & Reporting:

  Develop departmental QA policies, processes, and training standards

  Maintain comprehensive documentation of audit findings, feedback sessions, and training activities

  Provide reports on key performance indicators, including quality scores, audit outcomes, and training effectiveness, on a predetermined schedule

  Set timelines, communicate progress, track delivery, and elevate roadblocks or dependencies

• Collaboration & Support:

  Work closely with DRG Managers and the DRG Clinical Educator to ensure training and QA processes align with the company’s standards and objectives

  Serve as an expert resource for DRG Reviewers, QA/Trainers, and other staff members, answering questions and offering guidance on complex cases or procedures

  Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances

  Collaborate with operations, product, data analytics, and technology teams to recommend process and solution improvements based on QA findings

  Assist with research, special projects, and ad hoc claim reviews as needed

  Perform other duties as assigned

What experience you bring (Role Requirements)

Education Requirements:

• A bachelor’s degree in nursing (active/unrestricted license), health information management, or health administration is required
• An active, unrestricted nursing license is preferred
• Work experience may be considered in lieu of formal education at leadership discretion
• Certification (at least one of the following is required)

Certification (at least one of the following is required)

• RHIA - Registered Health Information Administrator
• RHIT - Registered Health Information Technician
• CCDS - Certified Clinical Documentation Specialist
• CDIP - Clinical Documentation Improvement Practitioner
• CCS - Certified Coding Specialist
• CIC - Certified Inpatient Coder

Qualifications:

• 5+ years of experience in healthcare billing and coding
• 3+ years of inpatient claims auditing, quality assurance, or recovery auditing experience, and/or inpatient Clinical Documentation Integrity experience
• Previous supervisory experience required
• Experience in production and team management
• Experience conducting training for clinical or coding staff
• Experience with readmission reviews
• Proven experience sharing DRG audit process knowledge with sales, marketing, and development teams

Skills

• Expert in DRG methodologies and classification systems, including MS-DRG, APR-DRG, and AP-DRG
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines
• Expertise in DRG validation, with in-depth knowledge of clinical criteria and documentation requirements to support code assignments
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
• Familiarity with Milliman and InterQual guidelines
• Proven ability to apply critical judgment in clinical and coding determinations
• Deep curiosity and analytical skills to understand root causes of events and behaviors
• Strong experience in data use and insights, including independently structuring and executing complex analyses
• Ability to provide clear, actionable feedback and coach staff to improved performance
• High standards of quality and attention to detail
• Strong organizational and time management skills
• Excellent written and verbal communication
• Ability to work independently with minimal supervision and collaboratively in teams

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

What We Offer:

• Top Medical/Dental/Vision offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary, 401(k) with company match
• Additional health and wellness benefits and perks
• Flexible and trusting environment where you’ll feel empowered to do your best work

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc. We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range.

Pay range: $130,000-$150,000 + Annual Bonus

Equal Employment Opportunity at Machinify

Equal Employment Opportunity at Machinify 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 let our recruiters know.

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