DRG Reviewer

Who We Are

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. Were constantly reimagining whats possible in our industry creating disruptively simple powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Location: This role is full remote

About the Opportunity

At Machinify were constantly reimagining whats possible in our industrycreating disruptively simple powerfully clear ways to maximize our clients financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions Team you will as a DRG Auditor be a key contributor responsible for conducting thorough DRG payment validation reviews including clinical and coding assessments of medical records and related documentation in accordance with contract-specific review criteria. This position requires an in-depth understanding of clinical guidelines coding protocols and regulatory requirements to ensure accurate payment determinations.

In this role you will meticulously document findings provide detailed clinical policy and regulatory support and collaborate with relevant stakeholders to ensure compliance with payment standards. Your expertise will be critical in ensuring that payment decisions are supported by accurate and complete documentation ultimately contributing to the integrity and efficiency of the payment process.

What youll do

• Audit patient medical records using clinical coding and payer guidelines to ensure accurate reimbursement.
• Provide clear evidence-based rationale for code recommendations or reconsiderations to providers or payers.
• Collaborate with team leaders to ensure thorough review of DRG denials.
• Conduct audits in alignment with organizational quality and timeliness standards.
• Use proprietary auditing systems proficiently to make consistent determinations and generate audit letters.
• Recommend improvements to the audit system to enhance efficiency.
• Ensure compliance with HIPAA regulations for protected health information.
• Perform other duties as assigned.

Education Requirements:

• An associate or bachelors degree in nursing (active/unrestricted license); or in health information management is required.
• Work experience may be considered in lieu of formal education at leadership discretion.

Certification (at least one of the following is required)

• RHIA - Registered Health Information Administrator
• RHIT- Registered Health Information Technician
  
• CCDS - Certified Clinical Documentation Specialist
• CDIP - Clinical Documentation Improvement Practitioner
• CCS - Certified Coding Specialist
• CIC - Certified Inpatient Coder

Qualifications:

• Inpatient claims auditing quality assurance or recovery auditing experience of 2 years or more required and/or Inpatient Clinical Documentation Integrity experience of 2 years or more required
• Strong focus on quality and attention to detail.
• Deep curiosity and analytical skills to understand root causes of events and behaviors.
• Proven ability to apply critical judgment in clinical and coding determinations.
• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
• Expert in DRG methodologies (e.g. MS & APR).
• Expertise in ICD-10-CM/PCS coding UHDDS definitions Official Coding Guidelines and AHAs Coding Clinic Guidelines.
• Ability to work independently and efficiently with minimal supervision.

What Success Looks Like

After 3 months

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• Youve gained confidence in your abilities and are starting to feel more comfortable in your role

After 1 year

• You have mastered the tasks and responsibilities of the position executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• Youve been entrusted with greater responsibility indicating the companys confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $85000-$105000 USD

• This is an exempt position. The salary range is for Base will be determined based on several factors including but not limited to skill set years of experience and the employees geographic location.

Whats in it for you

• PTO Paid Holidays and Volunteer Days
• Eligibility for health vision and dental coverage 401(k) plan participation with company match and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance short-term disability and parental leave.
• Remote and hybrid work options
  

What values well share with you

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results

At Machinify were reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity teamwork accuracy and flexibility. We do the right thing and we listen to the needs of our clients and their members. As tenured experts with unmatched experience we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally abandoning silos to bring innovative and accurate solutions to market. We invest in each other through ongoing education and team celebrations and we give back to our communities through dedicating days for volunteering. Together Machinify is making healthcare work better for everyone and were passionate about a future with better outcomes for all.

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 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 contact our People Operations team at. See our Candidate Privacy Notice at: Experience:

Senior IC