The Rawlings Group
DRG Clinical Validation Manager
The Rawlings Group, Roseville, California, United States, 95678
Overview
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering value, transparency, and efficiency to health plan clients. We are deployed by numerous health plans and represent millions of lives. Machinify provides a configurable, AI-powered platform along with industry expertise 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 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 related to clinical validation. This role supports the leadership, operations, selection, and content development teams. The role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of 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, development plans, and fostering a culture of accountability, innovation and clinical excellence. Internal and External Claim Support:
Coach, mentor, and provide performance feedback to internal team members. 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; conduct capacity planning to meet SLAs. Clinical Guidance:
Work with clinicians and MDs to provide guidance on clinical policies and references; provide feedback on policy performance and adjustments as needed. Work Coordination:
Manage daily queue inventory, assign and prioritize work, set goals, and coordinate team activities with regular updates. Performance Monitoring:
Monitor individual and team results to ensure timely completion per standards and guidelines. Quality Assurance/Improvement Oversight:
Establish and maintain quality assurance standards and continuous improvement processes for validation accuracy. Analytical Problem-Solving:
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 partners with evidence and references supporting standards and audit guidelines. Performance Reporting:
Manage data on KPIs, quality scores, workflows, savings, revenue projections, and inventory. Solution Development:
Collaborate on solution development with operations, product, data analytics, and technology; coordinate training on software releases. Timeline Management:
Set timelines, track progress, and escalate roadblocks as needed. Research and Special Projects:
Assist with research and ad hoc claim reviews. Other Duties:
Perform other duties as assigned. Qualifications
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 Certification: CCS, CCDS or CDIP Previous 3+ years supervisory experience required Experience
Proven experience working within a team and sharing DRG clinical validation audit process knowledge Experience with training or education preferred Proven experience with Clinical Validation Proven knowledge of MS-DRG, APR-DRG, AP-DRG Demonstrated curiosity and mastery in root-cause analysis Experience with recovery auditing preferred Strong data utilization and insights experience Ability to independently structure and execute complex analyses Production and team management experience Experience with Readmission and Short Stay reviews Ability to work efficiently with minimal supervision High standards of quality and attention to detail Deep understanding of Medicare and Commercial coding rules and PPS 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 with multiple monitors Proven success in a remote working environment Proficiency in Windows Office, including Excel, PowerPoint, Word, and Teams 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 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. What’s in it for you PTO, Paid Holidays, and Volunteer Days Health, vision and dental coverage, 401(k) with company match, and flexible spending accounts Tuition Reimbursement Company-paid benefits including life insurance, short-term disability, and parental leave Remote and hybrid work options Values
Ask why Think big Be humble Optimize for customer impact Deliver results 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 at-will employer. We participate in E-Verify as required by law. We do not inquire about salary history. If you require a reasonable accommodation, contact our People Operations team. See our Candidate Privacy Notice.
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Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering value, transparency, and efficiency to health plan clients. We are deployed by numerous health plans and represent millions of lives. Machinify provides a configurable, AI-powered platform along with industry expertise 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 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 related to clinical validation. This role supports the leadership, operations, selection, and content development teams. The role requires a proactive and strategic thinker with strong leadership and analytical skills to drive the success of 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, development plans, and fostering a culture of accountability, innovation and clinical excellence. Internal and External Claim Support:
Coach, mentor, and provide performance feedback to internal team members. 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; conduct capacity planning to meet SLAs. Clinical Guidance:
Work with clinicians and MDs to provide guidance on clinical policies and references; provide feedback on policy performance and adjustments as needed. Work Coordination:
Manage daily queue inventory, assign and prioritize work, set goals, and coordinate team activities with regular updates. Performance Monitoring:
Monitor individual and team results to ensure timely completion per standards and guidelines. Quality Assurance/Improvement Oversight:
Establish and maintain quality assurance standards and continuous improvement processes for validation accuracy. Analytical Problem-Solving:
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 partners with evidence and references supporting standards and audit guidelines. Performance Reporting:
Manage data on KPIs, quality scores, workflows, savings, revenue projections, and inventory. Solution Development:
Collaborate on solution development with operations, product, data analytics, and technology; coordinate training on software releases. Timeline Management:
Set timelines, track progress, and escalate roadblocks as needed. Research and Special Projects:
Assist with research and ad hoc claim reviews. Other Duties:
Perform other duties as assigned. Qualifications
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 Certification: CCS, CCDS or CDIP Previous 3+ years supervisory experience required Experience
Proven experience working within a team and sharing DRG clinical validation audit process knowledge Experience with training or education preferred Proven experience with Clinical Validation Proven knowledge of MS-DRG, APR-DRG, AP-DRG Demonstrated curiosity and mastery in root-cause analysis Experience with recovery auditing preferred Strong data utilization and insights experience Ability to independently structure and execute complex analyses Production and team management experience Experience with Readmission and Short Stay reviews Ability to work efficiently with minimal supervision High standards of quality and attention to detail Deep understanding of Medicare and Commercial coding rules and PPS 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 with multiple monitors Proven success in a remote working environment Proficiency in Windows Office, including Excel, PowerPoint, Word, and Teams 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 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. What’s in it for you PTO, Paid Holidays, and Volunteer Days Health, vision and dental coverage, 401(k) with company match, and flexible spending accounts Tuition Reimbursement Company-paid benefits including life insurance, short-term disability, and parental leave Remote and hybrid work options Values
Ask why Think big Be humble Optimize for customer impact Deliver results 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 at-will employer. We participate in E-Verify as required by law. We do not inquire about salary history. If you require a reasonable accommodation, contact our People Operations team. See our Candidate Privacy Notice.
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