Medical Director, DRG Audit & AI Innovation

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 60 health plans, including many of the top 20, and representing more than 160 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

About the Role

We are seeking a board-certified physician with strong inpatient coding and DRG audit expertise to join our team as Medical Director, DRG Audit & AI Innovation. This position combines the rigor of traditional DRG medical director responsibilities with the opportunity to directly shape the future of AI-powered clinical auditing.

Your primary responsibility will be to perform high-quality DRG clinical reviews, ensuring diagnostic and coding accuracy for hospital claims. In parallel, you will work with our product and engineering teams to refine how our AI agent learns from medical director decision-making. By blending expert review with feedback into the AI system, you will help transform traditional audits into seamless, AI-powered adjudication that can scale across the healthcare landscape.

What Success Looks Like

• High-quality, consistent DRG adjudications that uphold compliance and accuracy.

• Clear, appeal-ready narratives that raise the bar for audit transparency.

• Practical insights that help our AI agent “think like a physician auditor"

• A growing platform that reduces reviewer burden while maintaining clinical integrity.

What You'll Do:

• DRG Clinical Review (Core Duty):

  • Conduct DRG reviews to validate principal and secondary diagnoses, procedures, and associated coding.

  • Apply industry standard guidelines, coding rules, and organizational policies to each case.

  • Deliver clear, well-documented rationale for each determination, suitable for appeal-ready communication.

• AI Platform Contribution:

  • Translate case-based reasoning and medical judgment into structured feedback for the AI adjudicator.

  • Flag nuanced “maybe” cases, conflicting data, or gray zones to inform how the AI handles uncertainty.

  • Collaborate with policy and engineering teams to refine policy JSONs, decision trees, and narrative outputs.

  • Identify opportunities to capture clinical nuance (progression of illness, comorbid interactions) that improve AI accuracy.

• Quality & Education:

  • Serve as a subject matter expert for coding teams, nurses, and data scientists.

  • Provide input on audit guidelines, clinical validation criteria, and education materials.

  • Participate in quality improvement initiatives to enhance reviewer consistency and platform performance.
    

What You Bring:

• MD/DO with active, unrestricted license.

• Board certification in Internal Medicine, Surgery, Family Medicine, or related specialty with inpatient care experience.

• 3+ years of experience performing DRG audits, utilization management, or clinical validation reviews.

• Deep familiarity with ICD-10-CM/PCS, AHA Coding Clinic guidance, and CMS DRG policies.
  
  Preferred:

• Experience working with AI-powered or technology-enabled audit platforms.

• Demonstrated ability to translate clinical reasoning into structured or algorithmic formats.

• Strong written communication skills for audit documentation and collaborative product feedback.

• Comfort working in cross-functional teams (clinical, coding, engineering, product)

Why Join Us:

This is not a traditional medical director role. Here, you’ll do meaningful audit work and help architect how AI will transform clinical reviews. You’ll join a forward-thinking team that values physician judgment as the foundation of trustworthy automation.

Together, we will build the next generation of audit tools—turning fragmented checklists into cohesive clinical narratives, and making DRG validation more efficient, accurate, and fair for everyone in the healthcare system.

What We Offer:

• Work from anywhere in the US! Machinify is digital-first.

• Full Medical/Dental/Vision for employees & their families w/ 100% premium coverage options!

• Flexible and trusting environment where you’ll feel empowered to do your best work

• Unlimited PTO

• Competitive compensation package, 401(k) sponsorship
  

Equal Employment Opportunity at Machinify

Machinify is committed to hiring talented and qualified individuals with diverse backgrounds for all of its positions. Machinify believes that the gathering and celebration of unique backgrounds, qualities, and cultures enriches the workplace. 

See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/