Machinify · 1 day ago
DRG Clinical Support Lead
Roseville, CA
Full-time
Onsite
Mid, Senior Level
$120K/yr - $145K/yr
5+ years expMachinify is a leading healthcare intelligence company focused on delivering value and efficiency to health plan clients. The DRG Clinical Support Lead will develop and manage clinical solutions, requiring expertise in healthcare payment methodologies and claims recovery.
AnalyticsArtificial Intelligence (AI)Business IntelligenceMachine LearningPredictive AnalyticsSaaS
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
Qualification
Required
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
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
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
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
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 (12)
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
Company data provided by crunchbase