DRG Solutions Lead: Claims Auditing & Readmissions

Rawlings Company; United States; On-site; USD 125,000 - 140,000; Full time

Benefits offered by this job

Work from anywhere in the US

Medical/Dental/Vision

401(k)

Tuition reimbursement

Unlimited PTO

Flexible environment

Job summary

Machinify is seeking a DRG Manager to lead the development and management of clinical solutions, including MS and APR-DRG validation. You will supervise the DRG team, ensure accurate reviews, and maintain compliance with Medicare and commercial coding guidelines.

You will collaborate with cross-functional teams to implement DRG process improvements, monitor performance, and drive client satisfaction. This role supports our Complex Payment Solutions Team and requires strategic thinking,

Qualifications

• Bachelor's degree in health administration, business, nursing or related field.
• 5+ years in healthcare billing and coding.
• 3+ years in claims auditing and recovery auditing.
• Ability to lead DRG audit processes across teams.
• Strong knowledge of DRG classification systems and guidelines.
• Root-cause analysis and data-driven problem solving.
• Excellent collaboration with sales, marketing and product teams.

Responsibilities

• Lead development and management of clinical solutions including MS and APR-DRG validation.
• Oversee DRG team performance, scheduling, and reporting.
• Monitor regulatory updates and adjust rules accordingly.
• Guide claims review processes and client workflows.
• Provide evidence-based recommendations to partners and teams.
• Set timelines and manage project delivery.
• Develop and maintain departmental policies and training standards.
• Prepare and present performance reports and savings projections.

Skills

DRG validation

Team leadership

Data analytics

Medicare rules

Readmissions

MS-DRG/APR-DRG

Process improvement

Auditing

Education

Bachelor's degree

Job description

Machinify is seeking a DRG Manager to lead the development and management of clinical solutions, including MS and APR-DRG validation. You will supervise the DRG team, ensure accurate reviews, and maintain compliance with Medicare and commercial coding guidelines.

You will collaborate with cross-functional teams to implement DRG process improvements, monitor performance, and drive client satisfaction. This role supports our Complex Payment Solutions Team and requires strategic thinking,