DRG (Diagnosis-Related Group) Business Solutions Lead

About this role

About Us

Abacus Insights is transforming how data works for health plans. Our mission is simple: make healthcare data usable, so the people responsible for care and cost decisions can act faster, with confidence.

We help health plans break down data silos to create a single, trusted data foundation. That foundation powers better decisions—so plans can improve outcomes, reduce waste, and deliver better experiences for members and providers alike. Backed by $100M from top investors, we’re tackling big challenges in an industry that’s ready for change. Our platform enables GenAI use cases by delivering clean, connected, and reliable healthcare data to support automation, prioritization, and decision workflows—and it’s why we are leading the way.

Our innovation begins with people. We are bold, curious, and collaborative—because the best ideas come from working together. We embrace the thoughtful use of AI and automation to drive innovation and efficiency, and we look for individuals who are curious and adaptable—those excited to leverage emerging technologies to enhance how we work—while keeping human insight, connection, and our clients at the center of every decision.

Ready to make an impact? Join us and let’s build the future together.

About the Role

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.

What you bring to the team

• 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.

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

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