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DRG (Diagnosis-Related Group) Business Solutions Lead

2 hours, 15 minutes ago
India, United States
Full-time
Senior
Product Manager
Data Science and Analytics
Agile Azure Confluence Generative AI JIRA NLP
Apply Now
Abacus Insights

Abacus Insights

Abacus Insights simplifies healthcare data with intelligent solutions, unlocking data value and empowering health plans, consumers, and providers.

Insurance
51-250
Founded 2017
$82M raised
View All Jobs 5

Description

  • Define product requirements, audit methodologies, and business logic for scalable audit workflows.
  • Translate coding guidelines and CMS reporting rules into structured, codifiable audit logic.
  • Define and maintain the DRG audit prompt library across principal diagnosis, CC/MCC, PCS, POA, discharge disposition, transfer DRG, mechanical ventilation, and late-entry integrity.
  • Map audit signals to data domains, evidence requirements, and citation frameworks.
  • Partner with product management on vision and roadmap prioritization across coding validation, clinical validation, IBR, observation, and readmission workflows.
  • Work with data science to define clinical entity extraction targets for the NLP pipeline.
  • Test model outputs, identify false positives and negatives, and drive refinement loops.
  • Develop edit specifications, assumptions, test scenarios, and validation criteria for new audit capabilities and AI features.
  • Participate in client discovery sessions, demonstrations, solution reviews, and advisory discussions as a subject matter expert.
  • Represent the voice of the customer across the product lifecycle and use internal AI tools to prototype and communicate solutions.

Requirements

  • RN with 7+ years of progressive DRG audit experience in a payer or vendor environment.
  • Active coding credential: CCS, CIC, RHIA, or RHIT.
  • Deep knowledge of U.S. healthcare payer payment integrity programs, including pre-pay and post-pay audit strategies, vendor management, savings methodologies, recovery operations, and performance measurement.
  • Strong mastery of ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic, MS/APR-DRG Definitions Manual, and CMS POA Reporting Guidelines.
  • Experience in payer-side DRG coding validation audit or vendor-side DRG audit.
  • Direct experience defending or overturning DRG findings on appeal.
  • Clear written and verbal communication skills for translating technical coding rules into product requirements and executive narratives.
  • Familiarity with payer contract language, including readmission policies, audit rights, and lookback windows.
  • Understanding of payer regulatory, compliance, and audit considerations that affect payment integrity program design and execution.
  • Preferred: experience partnering with Product Management, Engineering, Data Science, or AI/ML teams; familiarity with prompt engineering, generative AI, NLP, and clinical document extraction; experience translating requirements into user stories or product specs; experience with client implementations, demos, or training; familiarity with Jira, Confluence, Azure DevOps, or similar tools; experience in a startup or high-growth healthcare technology company.

Benefits

  • Competitive leave and benefits.
  • Comprehensive health coverage.
  • Equity for every employee.
  • Growth-focused environment with support for professional development.
  • Remote role with US working hours (Eastern time zone).

Interested in this position?

Apply directly on the company website

Apply Now

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