What you’ll do
Conduct comprehensive reviews to validate the accuracy of billed charges against medical documentation, payer policies, coding guidelines, and industry standards to ensure appropriate reimbursement.
Apply coding guidelines across a broad range of outpatient services, including but not limited to Interventional Radiology, Radiation Oncology, injections and infusions, outpatient surgeries, implants, and observation services (including carve-outs).
Demonstrate a strong working knowledge of outpatient reimbursement methodologies, including Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classification (APC), and Enhanced Ambulatory Patient Grouping (EAPG).
Apply expert-level knowledge of NCCI edits, including appropriate modifier usage, as well as CPT and HCPCS coding guidelines.
Interpret and apply Medicare Local Coverage Determinations (LCDs) and National Coverage Determinations (NCDs).
Produce clear, concise, and defensible audit findings that accurately articulate reimbursement impact.
Develop and apply well-supported rationales for coding changes impacting reimbursement, referencing appropriate sources such as AMA Official Coding Guidelines, CPT Assistant, AHA Coding Clinic, payer policies, and other industry-standard resources.
Work effectively both independently and collaboratively within a production-driven environment.
Maintain established accuracy, quality, and productivity standards, including correct code assignment and thorough documentation of review outcomes.
Utilize computer applications and tools, including Grouper/Pricer software, ICD-10-CM encoders, and Microsoft Office products.
Adhere to the Standards of Ethical Coding as established by AHIMA.
Perform additional duties as assigned.
What experience you bring (Role Requirements)
Associate’s or Bachelor’s degree in Health Information Management, Medical Coding, or a related field
At least 2 years of experience performing pre-pay and/or post-pay reimbursement audits
Broad outpatient facility auditing experience, including specialty areas such as Interventional Radiology, injections and infusions, Radiation Oncology, Behavioral Health, and ambulatory surgery
Active certification including RHIT, RHIA, CCS (AHIMA), and/or CPC
5-7 years of experience in outpatient facility coding/auditing
Sound knowledge of ICD-10-PCS/CM, CPT, and HCPCs coding guidelines
Experience performing pre- and post-payment reimbursement audits
Expertise in Medicare regulations, including LCDs, NCDs, NCCI edits, OPPS, and APC methodologies
Demonstrated experience with APC payment methodologies, OPPS reimbursement logic, fee schedules, and payer contracts
Excellent verbal and written communication skills
Strong attention to detail and analytical skills
Experience with encoder and auditing tools (e.g., 3M, TrueBridge, Grouper/Pricer Software)
Pay range: $85,000 - $100,000, with the opportunity to earn quarterly bonuses. 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.
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
Additional health and wellness benefits and perks
Flexible and trusting environment where you’ll feel empowered to do your best work
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/
