DRG QA/Training Manager

About the role

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 escalate 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)

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:

Experience

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:

Work from anywhere in the US! Machinify is digital-first.

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

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. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/

Posting text as published by Machinify.

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