Senior Clinical Audit Subject Matter Expert

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 Clinical Audit Subject Matter Expert (SME) to drive quality testing and enhancement of our product in the payment integrity Audits space.

The ideal person for this role has an extensive background in facility-based nursing and clinical documentation improvement, and has experience performing clinical validation audits, as well as readmission, utilization management, and medical necessity determinations. We are looking for a high level of understanding of reimbursement guidelines, specifically Interqual/MCG and MS-DRG and APR-DRG payment systems.

What you'll do:

• Conduct comprehensive Clinical DRG validation audits of inpatient medical records ensuring compliance with payer policy and regulatory requirements to assess product performance.

• Conduct comprehensive Readmission and Medical Necessity determination reviews to determine compliance with payer policy, guidelines, and regulations.

• Serve as a clinical expert and resource for the product SME, product development, and engineering teams.

• Develop and refine clinical policies reflected in the product in collaboration with the HIM team and Medical Director(s). 

• Perform quality assessments by monitoring and reviewing inpatient and/or outpatient client accounts across the product, validating audit outcomes.

• Perform annual performance, randomized and quality assurance reviews to identify training opportunities. 

• Assist with edits, denials and appeals.

• Assist with the creation of various documents and reports as requested. Develop job aids and guides to assist users in audit platform use.

• Assist with other audit types as needed in support of product, audit opportunities, and concept development.

• Remain updated with the latest clinical guidelines and regulatory requirements.

• Familiarize yourself with payer partner policies, preferred clinical references, and applicable regulatory requirements.

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

• Identify potential claims outside of the concept where additional recoveries may be available. Suggest and develop high-quality, high-value concepts and or process improvement, tools, etc.

• Provide input on product enhancements and functionality.

• Serve as a liaison between payer/operations peers and product in interpreting business requirements.

What you’ll bring:

• Education 

  • Associates or Bachelor's degree in Nursing.

  • Equivalent experience of 10+ years experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG Clinical Validation Audit or Medical Necessity Determination setting.

• Certifications/Licensure

  • RHIA or RHIT 

  • CDIP or CCDS (required)

  • Inpatient Coding Credential - CCS or CIC preferred

  • RN with current licensure (required)

• Experience (required)

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

  • 5-10 years nursing experience in a facility setting.

  • 5-10 years experience performing documentation improvement or leading documentation improvement teams.

  • Experience developing audit selection criteria.

  • Adherence to payer, CMS and other regulatory compliance guidelines and mandates. 

  • Requires working knowledge of applicable industry-based standards.

  • Excellent written and verbal communication skills.

  • Proficiency in the use of EMR’s, Interqual/MCG, and encoders.

  
  

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.