DRG QA/Training Manager

Machinify

9d•$130,000 - $150,000•Remote

About The Position

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. The role oversees staff and work priorities, maintains the QA audit program, identifies audit trends and root causes, and implements corrective actions. It directs training and education, develops departmental QA and training standards, maintains documentation, and reports on quality and training performance. The manager also collaborates across operations, product, data analytics, and technology, serves as an expert resource, and supports research, special projects, and ad hoc claim reviews. This is a digital-first, work-from-anywhere-in-the-US position. The salary range is $130,000–$150,000 plus an annual bonus.

Requirements

A bachelor’s degree in nursing (with an active, unrestricted license), health information management, or health administration is required; work experience may be considered in lieu of formal education at leadership discretion.
At least one of the following certifications is required: RHIA, RHIT, CCDS, CDIP, CCS, or CIC.
At least 5 years of experience in healthcare billing and coding.
At least 3 years of inpatient claims auditing, quality assurance, or recovery auditing experience, and/or inpatient Clinical Documentation Integrity experience.
Previous supervisory experience.
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.
Expertise 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, including clinical criteria and documentation requirements supporting code assignments.
Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
Familiarity with Milliman and InterQual guidelines.
Ability to apply critical judgment in clinical and coding determinations.
Analytical skills and curiosity to understand root causes of events and behaviors.
Experience using data and insights, including independently structuring and executing complex analyses.
Ability to provide clear, actionable feedback and coach staff toward improved performance.
High standards of quality and attention to detail.
Strong organizational and time-management skills.
Excellent written and verbal communication skills.
Ability to work independently with minimal supervision and collaboratively in teams.
Experience working with multiple monitors.
Proven success in a remote working environment.
Proficiency with Windows office systems, including the full Microsoft Suite and Teams.
Advanced skills in Microsoft Excel, PowerPoint, and Word.
Experience with various software applications and collaboration with development teams.

Nice To Haves

An active, unrestricted nursing license is preferred.

Responsibilities

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 to support the 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.
Own the QA audit program for new and existing DRG Reviewers, ensuring accuracy, compliance, and alignment with 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 identifies improvement areas and recognizes high performance.
Identify problems and trends in audit results, determine root causes, and implement corrective action plans.
Collaborate with leadership to improve audit accuracy, workflow efficiency, and reviewer performance.
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 on policy updates, skill development, and performance enhancement.
Direct the development and maintenance of training materials and resources, using audit trends to target content.
Evaluate training effectiveness and adjust content based on quality results.
Develop departmental QA policies, processes, and training standards.
Maintain comprehensive documentation of audit findings, feedback sessions, and training activities.
Provide scheduled reports on quality scores, audit outcomes, and training effectiveness.
Set timelines, communicate progress, track delivery, and escalate roadblocks or dependencies.
Work with DRG Managers and the DRG Clinical Educator to align training and QA processes with company standards and objectives.
Serve as an expert resource for DRG Reviewers, QA/Trainers, and other staff, 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.