DRG (Diagnosis-Related Group) Business Solutions Lead

• 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.

• 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.

• 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.