DRG Solutions Lead: AI-driven Payment Integrity (Remote)

Abacus Insights; United States; On-site; USD 150,000 - 230,000; Full time

Benefits offered by this job

Unlimited PTO

Work from anywhere

Comprehensive health coverage

Equity for every employee

Growth-focused environment

Home office setup allowance

Monthly cell phone allowance

Job summary

Abacus Insights is seeking a DRG Business Solutions Lead to drive clinical-coding domain authority and translate audit expertise into scalable product features. You will encode DRG logic into product capabilities, shaping audit workflows and AI-driven components with product, AI engineering, and clinical leadership.

You will partner with data science to define extraction targets, review model outputs, and develop validation criteria, ensuring defensible, high-quality audit results across the

Qualifications

• RN with 7+ years of progressive DRG audit experience in a payer or vendor space.
• Deep knowledge of U.S. healthcare payer payment integrity programs, including pre-pay and post-pay audit strategies.
• Active coding credential: CCS, CIC, RHIA, or RHIT.
• Deep mastery of ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic, MS/APR-DRG Definitions Manual, and CMS POA Guidelines.

Responsibilities

• Define product requirements, audit methodologies, and business logic to support accurate, scalable audit workflows.
• Translate coding guidelines into structured, codifiable audit logic.
• Define and maintain the DRG audit prompt library and citation framework.
• Map audit signals to data domains and evidence requirements.
• Partner with product management on roadmaps across coding validation and related areas.
• Collaborate with AI/ML teams to define extraction targets and validation criteria.

Skills

DRG audit

Payer experience

Coding credentials

ICD-10-CM/PCS

Cross-functional collaboration

Payer contracts

Regulatory knowledge

Education

CCS, CIC, RHIA, RHIT

Tools

Jira

Confluence

Azure DevOps

Job description

Abacus Insights is seeking a DRG Business Solutions Lead to drive clinical-coding domain authority and translate audit expertise into scalable product features. You will encode DRG logic into product capabilities, shaping audit workflows and AI-driven components with product, AI engineering, and clinical leadership.

You will partner with data science to define extraction targets, review model outputs, and develop validation criteria, ensuring defensible, high-quality audit results across the