What you’ll do
Enhance and Review Clinical Solutions: Utilize expertise to assist in the enhancement and review of readmissions, place of service, and other clinical solutions.
Collaborative Development: Work with a multi-disciplinary team of programmers, operations staff, product leaders, and auditors to bring DRG process ideas from creation to implementation.
Regulatory Monitoring: Assess and adjust written rules by monitoring their effectiveness, keeping up with regulatory updates, and making necessary changes.
Team Leadership: Lead the DRG team by providing guidance, counsel, and development plans to ensure long-term retention and professional growth of DRG staff.
Claims Review Management: Oversee the entire process of clinical claims review, understanding various client configurations and workflows.
Operational Oversight: Manage scheduling, reporting to management, issue resolution, and execution of plans.
Work Coordination: Assign and prioritize work, set goals, and coordinate daily activities of the team. Provide regular updates and communication through one-on-one and team meetings.
Performance Monitoring: Monitor individual and team results to ensure timely completion of work in accordance with department standards and medical policy guidelines.
Analytical Problem-Solving: Demonstrate analytical skills to identify problems and trends, develop solutions, and implement action plans.
Policy and Process Development: Develop departmental policies, processes, and training standards.
Support and Evidence: Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
Performance Reporting: Provide reports on key performance indicators, including quality scores, workflows, savings, revenue projections, and inventory on a predetermined schedule.
Solution Development: Collaborate with a multi-disciplinary team to suggest solution development, including operations, product, data analytics, and technology.
Timeline Management: Set timelines and ensure communication on progress, tracking delivery, and escalating roadblocks or dependencies.
Program Deployment: Design and deploy effective programs/solutions to identify and correct claims with aberrant results, providing feedback to resolve root causes.
Research and Special Projects: Assist with research, special projects, and ad hoc claim reviews as needed.
Other Duties: Perform other duties as assigned.
What you'll bring
Bachelor’s degree (health administration, business, nursing)
Equivalent experience of 5+ years in healthcare billing and coding
Equivalent experience of 3+ years in claims auditing and recovery auditing
Proven experience working within a team, sharing DRG audit process knowledge with sales, marketing, and development teams
Proven knowledge of classification systems, including MSDRG, APR DRG, AP DRG, and outpatient payment systems such as APCs and EAPGs
Demonstrated curiosity and mastery in understanding the root cause of events and behaviors
Strong experience in data utilization and insights
Experience independently structuring and executing complex analyses
Familiarity with Milliman and InterQual guidelines
Expertise in DRG validation
Experience in production and team management
Experience with Readmission reviews
Ability to work efficiently and effectively with minimal supervision
High standards of quality and attention to detail
Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
Superior knowledge of healthcare coding, billing, and reimbursement
Expert knowledge of clinical criteria documentation requirements
Subject matter expertise in APR-DRG validation, Readmissions, and Place of Service
What we offer
Work from anywhere in the US! Machinify is digital-first.
Top Medical/Dental/Vision offerings
FSA/HSA
Tuition reimbursement
Competitive salary, 401(k) with company match
Unlimited PTO
Additional health and wellness benefits and perks
Flexible and trusting environment where you’ll feel empowered to do your best work
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 meaningful equity, excellent healthcare, flexible time off, and other benefits and perks.
Pay range: $125,000-$140,000 USD, plus annual bonus.
Equal Employment Opportunity at Machinify
We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/
