Machinify · 4 hours ago
DRG Reviewer (Onsite)
Nashville Metro
Full-time
Onsite
Mid, Senior Level
$90K/yr - $110K/yr
5+ years expMachinify is a leading healthcare intelligence company focused on delivering value and efficiency to health plan clients. The Onsite DRG Reviewer is responsible for auditing medical records and ensuring accurate DRG assignments while collaborating with team leaders and maintaining compliance with healthcare regulations.
AnalyticsArtificial Intelligence (AI)Business IntelligenceMachine LearningPredictive AnalyticsSaaS
Responsibilities
Claims Review: Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy
Written Communication: Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes
Collaboration: Collaborate with team leaders to ensure DRG denial is thoroughly reviewed
Coding Knowledge: Maintains expert knowledge of ICD-10-CM/PCS coding conventions and rules, Official Coding Guidelines and American Hospital Association (AHA) Coding Clinic
Quality and Time Management: Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team, meets productivity requirements
Technically savvy: Ability to use multiple tools, provider systems, and different medical records systems to perform audits in a comprehensive and timely manner
Proficiency: Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and rationales
HIPAA Compliance: Assures HIPAA compliance for protected health information
Presentation skills: Participates in exit interviews with the client summarizing audit findings, which can vary depending on client/ facility
Practice Standards: Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association
Other duties as assigned
Qualification
Required
National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS)
Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years' experience performing DRG validation
Excellent oral and written communication skills
Comprehensive knowledge of the DRG structure and regulatory requirements
Associate or bachelor's degree in nursing (active/unrestricted license); or Associate or bachelor's degree in health information management; or Work experience may be considered in lieu of formal education at leadership discretion
Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required
Inpatient Clinical Documentation Integrity experience of 2 years or more required
Exhibits high standards for quality and attention to detail
Displays deep patterns of curiosity and mastery to understand the root cause of events and behaviors
Demonstrated ability to apply critical review judgment to make clinical and/or coding determinations
Solid knowledge and understanding of clinical criteria and documentation requirements to successfully substantiate code assignments
Subject matter expert in DRG methodologies (e.g., MS & APR)
Subject matter expert in ICD-10-CM/PCS coding methodologies, UHDDS definitions, Official Coding Guidelines and AHA's Coding Clinic Guidelines
Demonstrates ability to work efficiently and effectively with minimal direct supervision
Experience working with laptops and multiple monitors
Experience working remotely
Working knowledge of Windows office systems including full Microsoft Suite and Teams
Experience with various forms of software and experience engaging development teams
Experience with Encoder/Grouper programs (TruCode/3M) and/or similar coding and auditing tools
Requires the ability to sit or stand for long periods of time, 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
Requires ability to travel to multiple locations, as scheduled, within the commutable vicinity of residence
Preferred
Previous auditing/ recovery experience preferred
Highly recommend ICD-10 specialized training
Proven self-direction in the planning and execution of DRG validation and recovery functions
Demonstrated exemplary professional coding judgment
Confirmed effective communication in staff supervision and teaching
Proven operations analysis, including productivity and financial skills
Ability to adhere to the highest ethical standards including honesty, integrity, dedication and leadership
Demonstrated ability to gain support for ideas and lead others to accomplish objectives
Demonstrated success rate in selection of cases that result in overpayment/recovery
Organization, flexibility and multiple task/project orientation to handle duties assigned
Skill in focusing on desired results, determining what is important and urgent, clarifying next steps, and delegating effectively to meet deadlines and achieve desired results
Must possess excellent oral, written and presentation skills
Demonstrated proficiency in multiple computer applications (MS Office), DRG Grouper/Pricer software, and encoder software
Benefits
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
Company
Machinify
Machinify is a SaaS platform that enables non-technical enterprises to build AI-powered products and processes.
1001-5000 employees
H1B Sponsorship
Machinify has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (6)
2024 (6)
2023 (3)
2022 (3)
2021 (4)
2020 (5)
Funding
Current Stage
Late StageTotal Funding
$12.79MKey Investors
Battery Ventures
2025-01-10Acquired
2018-10-08Series A· $10M
2016-03-15Seed· $2.79M
Leadership Team
Edward Lichty
Strategic Operations
Prasanna Ganesan
EVP & Chief Product Officer
Recent News
2025-12-19
Dallas Morning News
2025-10-24
globallegalchronicle.com
2025-10-24
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