Senior DRG Audit SME

Machinify is the leading provider of AI-powered software products that transform healthcare claims and payment operations. Each year, the healthcare industry generates over $200B in claims mispayments, creating incredible waste, friction and frustration for all participants: patients, providers, and especially payers. Machinify’s revolutionary AI-platform has enabled the company to develop and deploy, at light speed, industry-specific products that increase the speed and accuracy of claims processing by orders of magnitude.

Machinify is seeking a Senior DRG Audit Subject Matter Expert (SME) to drive quality testing of two of our products in the Audits and Utilization Management space.

The ideal person for this role has an extensive background in either facility-based nursing, clinical documentation, outpatient coding and inpatient coding and has a high level of understanding in reimbursement guidelines, specifically an understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. 

What you'll do:

• Conduct comprehensive DRG validation audits of inpatient medical records to ensure accurate coding, adherence to coding guidelines, and compliance with regulatory requirements 

• Serve as an inpatient coding expert and resource for the coding teams and other departments; ensuring that information is accurate and current, meeting professional coding standards.

• Develop and refine coding policies and procedures in collaboration with the HIM team. 

• Quality Review - Monitors and audits inpatient and/or outpatient client accounts across the system, looking at facility coding for inpatient and/or outpatient accounts. Performs annual performance, randomized and quality assurance reviews to assess comprehension of training efforts. Also assists other external and regulatory audits.

• Edits/Denials/Coding - Assists with edits, denials and appeals.

• Reporting - Assists with the creation of various documents and reports as requested. Immediately provides reports related to compliance risks when requested.

• Payment integrity- Assists with other audit types as needed in support of product, audit opportunities, and concept development.

• Remain updated with the latest coding guidelines and regulations

• Achieve the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation 

• Identify New Claim Types/Overpayment Opportunities.  Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high-quality, high-value concepts and or process improvement, tools, etc.

What you’ll bring:

• Education (at least one of the following is required):

  • Associates or Bachelor's degree in Nursing 

  • Associate or Bachelor's degree in Health Information Management (RHIA or RHIT) 

  • Equivalent experience of 5+ years experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting.

• Coding Certifications:

  • RHIA or RHIT

  • Inpatient Coding Credential - CCS or CIC preferred

• Experience (required):

  • 5 -10 years of working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.

  • Experience with outpatient coding (CPT, HCPCS, and modifiers)

  • Experience developing audit selection criteria to identify DRG coding errors and overpayments.

  • Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG & ICD-10. 

  • Requires working knowledge of applicable industry-based standards.

  • Excellent written and verbal communication skills.

  • Proficiency in the use of EMR’s and encoders.

What we offer:

• A flexible and trusting environment where you'll feel empowered to do your best work.

• Work from anywhere in the US! Our team is distributed and most of us work from home.

• Hardworking and supportive colleagues, and a leadership team that understands the importance of recruiting and retaining top talent.

• Incredible medical, vision, and dental benefits for employees & their families.

• Competitive salary and equity, 401(k) sponsorship.

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc. We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range. Salary is one component of the total compensation package, which includes excellent healthcare, flexible time off, and other benefits and perks to meet the needs of each individual.

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.