Auditor, Diagnosis Related Group (Drg) Validation

Machinify is a revolutionary healthcare software company with a mission to ensure that patients get the right medical treatment, at the right time, at the right price. Our cloud-based Machinify AI platform leverages the latest advances in machine learning, large language models, data analytics, and cloud processing to solve previously intractable problems, transforming healthcare administration and payment operations.
Machinify is seeking a DRG Validation Auditor expert to drive quality testing of two of our products in the Audits and Utilization Management space.
The ideal person for this role has an extensive background in either facility-based nursing, clinical documentation, outpatient coding and inpatient coding and has a high level of understanding in reimbursement guidelines, specifically an understanding of the MS-DRG, AP-DRG and APR-DRG payment systems.
What you'll do:

• Conduct comprehensive audits of inpatient medical records to ensure accurate coding, adherence to coding guidelines, and compliance with regulatory requirements
• Serve as an inpatient coding expert and resource for the coding teams and other departments.
• Develop and refine coding policies and procedures in collaboration with the HIM team.
• Remain updated with the latest coding guidelines and regulations
• Achieve the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation
• Identify New Claim Types. Identifies potential claims outside of the concept where additional recoveries may be available. Suggests and develops high-quality, high-value concepts and or process improvement, tools, etc.

What you'll bring:

• Education (at least one of the following is required)
  
  • Associates or Bachelor's degree in Nursing
  • Associate or Bachelor's degree in Health Information Management (RHIA or RHIT)
  • Equivalent experience of 5+ years experience in claims auditing, quality assurance, or recovery auditing, ideally in a DRG / Clinical Validation Audit setting or a hospital environment.
• Coding Certifications
  
  • RHIA or RHIT
  • Inpatient Coding Credential - CCS or CIC preferred
• Experience (required)
  
  • 5 -10 years of working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG with a broad knowledge of medical claims billing/payment systems provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
  • Experience with outpatient coding (CPT, HCPCS, and modifiers)
  • Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates. Requires expert coding knowledge - DRG & ICD-10.
  • Requires working knowledge of applicable industry-based standards.
  • Excellent written and verbal communication skills.

What we offer:

• A flexible and trusting environment where you'll feel empowered to do your best work.
• Work from anywhere in the US! Our team is distributed and most of us work from home.
• Hardworking and supportive colleagues, and a leadership team that understands the importance of recruiting and retaining top talent.
• Incredible medical, vision, and dental benefits for employees & their families.
• Competitive salary and equity, 401(k) sponsorship.

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. The base salary range for this role is $100k to $150k. 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 to meet the needs of each individual.
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.