State Licensed DRG Solutions Lead

Job Summary

Partnering with product and engineering teams, the full-time remote State Licensed DRG Solutions Lead will define product requirements, translate clinical coding guidelines into audit logic, and validate AI outputs to enhance healthcare payment integrity solutions.

Key responsibilities

• Define product requirements and audit methodologies to support scalable audit workflows
• Translate clinical coding guidelines into structured audit logic and maintain the DRG audit prompt library
• Collaborate with data science to refine NLP models and ensure client needs are reflected in product design

Required qualifications

• Registered Nurse (RN) with 7+ years of 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 and audit strategies
• Mastery of ICD-10-CM/PCS coding guidelines and CMS POA Reporting Guidelines
• Experience defending or overturning DRG findings on appeal