Abacus Insights - DRG (Diagnosis-Related Group) Business Solutions Lead
Requirements
• RN with 7+ years of progressive DRG audit experience in a payer or vendor space. • 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. • Active coding credential: CCS, CIC, RHIA, or RHIT. • Deep mastery of ICD-10-CM/PCS Official Coding Guidelines, AHA Coding Clinic, MS/APR-DRG Definitions Manual, and CMS POA Reporting Guidelines. • Payer-side DRG coding validation audit (commercial, MA, or Medicaid) • Vendor-side DRG audit • Direct experience defending or overturning DRG findings on appeal. • Clear written and verbal communication — ability to translate technical coding rules into product requirements, finding letters, and executive narratives. • Familiarity with payer contract language — readmission policies, audit rights, lookback window. • Understanding of payer regulatory, compliance, and audit considerations that impact payment integrity program design and execution. • What we would like to see, but not required • Experience partnering with Product Management, Engineering, Data Science, or AI/ML teams to develop healthcare technology solutions. • Familiarity with prompt engineering, generative AI, NLP, and clinical document extraction technologies. • Experience translating clinical or coding requirements into business requirements, user stories, or product specifications. • Experience supporting client implementations, product demonstrations, training programs, or customer-facing engagements. • Familiarity with Jira, Confluence, Azure DevOps, or similar product development and agile collaboration tools. • Experience working in a startup, high-growth healthcare technology company, or product-focused organization. • Compensation: Compensation for this role is based on experience, skills, and location, and includes base salary plus eligibility for performance bonuses and equity grants.
Responsibilities
• Define product requirements, audit methodologies, and business logic to support accurate, scalable audit workflows. • Translate Official Coding Guidelines, AHA Coding Clinic, MS/APR-DRG Definitions Manual, and CMS POA Reporting Guidelines into structured, codifiable audit logic. • Define and maintain the DRG audit prompt library (principal dx, CC/MCC, PCS, POA, discharge disposition, transfer DRG, mechanical ventilation, late-entry integrity). • Map audit signal to its data domain, evidence requirements, and citation framework. • Partner with product management on product vision, roadmap prioritization across coding validation, clinical validation, IBR, observation, and readmission wedges. • AI / NLP Model Partnership • Partner with data science to define the clinical entity extraction targets the NLP pipeline must capture from parsed medical records. • Test and review model outputs, flag false positives and negatives, and drive model refinement loops. • Develop edit specifications, assumptions and validation criteria. • Participate in client discovery sessions, product demonstrations, solution reviews, and customer advisory discussions as a DRG and payment integrity subject matter expert. • Represent the voice of the customer throughout the product lifecycle, ensuring client needs, operational realities, and market demands are reflected in product design and roadmap decisions. • Develop test scenarios, expected outcomes, and validation criteria for new audit capabilities and AI-driven features. • Utilize internal AI-enabled tools to quickly create prototypes, visualize workflows, and showcase product functionality, enabling effective communication of product vision and business value. • Champion the use of internal AI tools to accelerate ideation, solution design, and demonstration of product capabilities, helping stakeholders understand requirements, opportunities, and proposed outcomes.
Benefits
• What you’ll get in return • Unlimited paid time off – recharge when you need it • Work from anywhere – flexibility to fit your life • Comprehensive health coverage – multiple plan options to choose from • Equity for every employee – share in our success • Growth-focused environment – your development matters here • Monthly cell phone allowance – stay connected with ease #LI-SB1 #LI-Remote
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