Improving people’s lives by harnessing the healthcare data explosion through an intelligent data integration platform.
DRG Business Solutions Lead
Location
Worldwide
Posted
4 days ago
Salary
0
Seniority
Lead
No structured requirement data.
Job Description
DRG Business Solutions Lead
Abacus Insights
Role Description The DRG Business Solutions Lead is the clinical-coding domain authority who will partner directly with product, AI engineering, and clinical leadership to translate DRG audit expertise into product capability. This is not a traditional auditor seat — this is a builder seat. You'll sit at the center of how Abacus builds trustworthy AI for healthcare payment integrity — defining the audit logic, shaping the prompt libraries, validating AI outputs, and owning the defensibility standard that every Abacus finding must meet. It's a rare seat for a DRG expert: instead of applying your coding and appeal-defense expertise one claim at a time, you'll encode it into a product used at scale, working shoulder-to-shoulder with product, engineering, and clinical leadership to shape how the next generation of audit technology gets built. Your day to day - 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. Qualifications - 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. - Demonstrated experience in at least one of the following: - 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. Requirements - 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. Benefits - 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 - Home office setup allowance – one-time support to get you started - Monthly cell phone allowance – stay connected with ease Company Description As a mission-led technology company helping to drive better healthcare outcomes, Abacus Insights believes that the best innovation and value we can bring to our customers comes from diverse ideas, thoughts, experiences, and perspectives. Therefore, we dedicate resources to building diverse teams and providing equal employment opportunities to all applicants. Abacus prohibits discrimination and harassment regarding race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. At the heart of who we are is a commitment to continuously and intentionally building an inclusive culture—one that empowers every team member across the globe to do their best work and bring their authentic selves. We carry that same commitment into our hiring process, aiming to create an interview experience where you feel comfortable and confident showcasing your strengths. If there’s anything we can do to support that—big or small—please let us know.
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