The Rawlings Group
California Office - Roseville, CA 95661
Overview Salary Range:
$120,000.00 - $145,000.00 Salary/year
Who We Are 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 60 health plans, including many of the top 20, and representing more than 160 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.
Location Remote
About the Role The DRG Clinical Support Lead is responsible for the development and management of our clinical solutions, including Readmissions, MS-DRG, and APR-DRG validation clinical concepts. This role will also take part in managing the selection process, volume, and results, across platforms. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims recovery, and MS & APR-DRG expertise is essential.
Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed for proof of concepts. This role also will be responsible for managing selections across platforms and ensuring accuracy of scope and monitoring and adjustment of volume and results. This role requires an expert in clinical areas in addition to payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance.
Essential Duties and Responsibilities
Content Development:
Develop innovative strategies to enhance claim selection processes for both pre- and post-payment, significantly contributing to payment integrity for our clients.
Data Analysis and Organization:
Leverages data analysis expertise and strong organizational skills to innovate and optimize proprietary tools, ensuring the highest standards of payment accuracy.
Claim Selection Methodology:
Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
Claim Selection Management:
Manage and monitor selections across business and ensure appropriate volume and cadence.
Enhance and Review Clinical Solutions:
Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
Collaborative Development:
Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
Regulatory Monitoring:
Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
Performance Monitoring:
Monitor performance of current and new concepts and continue to adjust to enhance performance and output.
Analytical Problem‑Solving:
Demonstrate analytical skills to 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 internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
Solution Development:
Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
Timeline Management:
Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
Program Deployment:
Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
Research and Special Projects:
Assist with research, special projects, and ad hoc claim reviews as needed.
Proof of Concept Assistance:
When necessary, provide review support for proof of concepts or sales support.
Other Duties:
Perform other duties as assigned.
Qualifications
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
Experience
Extensive experience in MS-DRG and APR-DRG methodology for clinical content rules development and claim selections
Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs
Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
Strong experience in data utilization and insights
Experience independently structuring and executing complex analyses
Familiarity with Milliman and InterQual guidelines
Expertise in DRG validation
Experience in production and team management
Experience with Readmission reviews
Ability to work efficiently and effectively with minimal supervision
High standards of quality and attention to detail
Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures
Expert knowledge of clinical criteria documentation requirements
Subject matter expertise in MS & APR-DRG validation, and Readmissions
Experience providing clinical support during peer‑to‑peer reviews and client reviews
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
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
Requires a normal range of vision and hearing, with or without accommodations
Position is not substantially exposed to adverse environmental conditions
Pay range $120,000 - $145,000 USD
This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.
What’s in it for you
PTO, Paid Holidays, and Volunteer Days
Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
Tuition Reimbursement
Eligibility for company‑paid benefits including life insurance, short‑term disability, and parental leave.
Remote and hybrid work options
What values we’ll share with you
Ask why
Think big
Be humble
Optimize for customer impact
Deliver results
Our Culture and Commitment 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 contact our People Operations team at Machinify_Careers@machinify.com. See our Candidate Privacy Notice at https://www.machinify.com/candidate-privacy-notice/.
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Overview Salary Range:
$120,000.00 - $145,000.00 Salary/year
Who We Are 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 60 health plans, including many of the top 20, and representing more than 160 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.
Location Remote
About the Role The DRG Clinical Support Lead is responsible for the development and management of our clinical solutions, including Readmissions, MS-DRG, and APR-DRG validation clinical concepts. This role will also take part in managing the selection process, volume, and results, across platforms. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. Proven experience in rule and content creation, claims recovery, and MS & APR-DRG expertise is essential.
Key responsibilities include developing content, tracking performance, providing implementation and client support, conducting research, and reviewing claims as needed for proof of concepts. This role also will be responsible for managing selections across platforms and ensuring accuracy of scope and monitoring and adjustment of volume and results. This role requires an expert in clinical areas in addition to payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance.
Essential Duties and Responsibilities
Content Development:
Develop innovative strategies to enhance claim selection processes for both pre- and post-payment, significantly contributing to payment integrity for our clients.
Data Analysis and Organization:
Leverages data analysis expertise and strong organizational skills to innovate and optimize proprietary tools, ensuring the highest standards of payment accuracy.
Claim Selection Methodology:
Utilizes a comprehensive understanding of claim selection methods to refine and execute methodologies that enhance claim selection strategies, particularly focused on inpatient claims.
Claim Selection Management:
Manage and monitor selections across business and ensure appropriate volume and cadence.
Enhance and Review Clinical Solutions:
Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
Collaborative Development:
Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
Regulatory Monitoring:
Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
Performance Monitoring:
Monitor performance of current and new concepts and continue to adjust to enhance performance and output.
Analytical Problem‑Solving:
Demonstrate analytical skills to 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 internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
Solution Development:
Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
Timeline Management:
Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
Program Deployment:
Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
Research and Special Projects:
Assist with research, special projects, and ad hoc claim reviews as needed.
Proof of Concept Assistance:
When necessary, provide review support for proof of concepts or sales support.
Other Duties:
Perform other duties as assigned.
Qualifications
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
Experience
Extensive experience in MS-DRG and APR-DRG methodology for clinical content rules development and claim selections
Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs
Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
Strong experience in data utilization and insights
Experience independently structuring and executing complex analyses
Familiarity with Milliman and InterQual guidelines
Expertise in DRG validation
Experience in production and team management
Experience with Readmission reviews
Ability to work efficiently and effectively with minimal supervision
High standards of quality and attention to detail
Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures
Expert knowledge of clinical criteria documentation requirements
Subject matter expertise in MS & APR-DRG validation, and Readmissions
Experience providing clinical support during peer‑to‑peer reviews and client reviews
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
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
Requires a normal range of vision and hearing, with or without accommodations
Position is not substantially exposed to adverse environmental conditions
Pay range $120,000 - $145,000 USD
This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location.
What’s in it for you
PTO, Paid Holidays, and Volunteer Days
Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
Tuition Reimbursement
Eligibility for company‑paid benefits including life insurance, short‑term disability, and parental leave.
Remote and hybrid work options
What values we’ll share with you
Ask why
Think big
Be humble
Optimize for customer impact
Deliver results
Our Culture and Commitment 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 contact our People Operations team at Machinify_Careers@machinify.com. See our Candidate Privacy Notice at https://www.machinify.com/candidate-privacy-notice/.
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