DRG Dispute 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.

Job Summary

The DRG Dispute Reviewer is responsible for evaluating provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. This role requires advanced knowledge of MS-DRG and APR-DRG methodologies clinical validation coding guidelines and payer policies. Using clinical and coding expertise the reviewer independently assesses documentation to ensure audit decisions are accurate defensible and compliant. This position plays a vital role in supporting regulatory compliance identifying and recovering overpayments and promoting proper documentation and reimbursement practices across healthcare systems.

Duties and Responsibilities

• Dispute Review: Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.
• Medical Record Analysis: Review inpatient medical records UB-04s and documentation to ensure correct DRG assignment and adherence to coding billing and payment guidelines.
• DRG Validation: Apply clinical validation and coding principles to support or overturn DRG audit findings using MS-DRG and APR-DRG grouping logic.
• Written Justification: Prepare clear concise and evidence-based rationales to support determinations for clients providers or payers.
• Coding Expertise: Maintain expert knowledge of ICD-10-CM/PCS coding guidelines UHDDS definitions and AHA Coding Clinic updates.
• Clinical Judgment: Use clinical acumen to assess medical necessity documentation sufficiency and code assignment accuracy.
• Collaboration: Work closely with audit leads and team members to ensure consistency and quality in dispute resolutions.
• Quality & Productivity: Meet performance standards for accuracy timeliness and productivity in dispute review and audit completion.
• Compliance: Adhere to HIPAA guidelines industry best practices and AHIMAs Standards of Ethical Coding.
• Client Communication: Participate in client meetings including presenting audit results when required.
• Tool Utilization: Use proprietary audit platforms encoders and medical record systems efficiently and effectively.
• Other Duties: Perform additional tasks as assigned to support audit operations and client needs.

Required Education (One of the following):

• 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.

Required Certifications (At least one of the following):

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

Experience:

• Minimum 3 years of inpatient hospital coding (IPPS reimbursement)
• Minimum 4 years DRG validation (clinical and coding)
• Experience in DRG dispute reviews clinical validation and recovery audits strongly preferred
• Prior experience in inpatient clinical documentation integrity (CDI) is a plus
  

Skills and Competencies:

• Expert-level knowledge of ICD-10-CM/PCS coding systems MS-DRG/APR-DRG methodologies and official guidelines
• Strong analytical and critical thinking skills for complex case reviews
• Ability to write clear professional rationales supported by clinical and coding evidence
• High attention to detail accuracy and compliance
• Able to work independently with minimal supervision in a remote environment
• Technically proficient with:
  • Medical record systems and audit platforms
  • Encoder/grouper tools (e.g. TruCode 3M)
  • Microsoft Office Suite (Excel Word Outlook Teams)
    

Work Environment & Physical Demands:

• Remote-based work with ability to manage multiple software tools simultaneously
• Must be able to sit or stand for extended periods; occasional lifting (up to 25 lbs)
• Requires a normal range of vision and hearing with or without accommodations
• Position is not substantially exposed to adverse environmental conditions

This is an exempt position. The salary range is between $100000 and $115000 USD

For Salary position only: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