DRG Quality Assurance/Training Manager

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