Pre/Post Pay Data Mining SME

Summary

Join Machinify, a leading provider of AI-powered healthcare software, as a Subject Matter Expert (SME) for pre and/or post-pay data mining. You will lead the development and implementation of new data mining initiatives for our clients, contributing to client growth and product enhancement. This advanced role requires extensive healthcare claims auditing, processing, and coding experience, along with a deep understanding of payment guidelines. You will guide the work of others, collaborate with various teams, and constantly develop new auditing concepts. The ideal candidate possesses strong analytical, problem-solving, and communication skills, thrives in a fast-paced environment, and is committed to achieving high-quality results. Machinify offers a competitive salary and benefits package, including remote work options and a flexible environment.

Requirements

• Have 10+ years of relative experience
• Be a Subject Matter Expert in healthcare, including data mining (pre and post-pay), client engagement experience, researching, developing, document creation, policy creation, healthcare claims pricing, and healthcare data
• Possess a strong ability to "figure it out" – self-teach, research, and find correct answers or solutions
• Have the ability to review payment information against Medicare and payer billing guidelines to make determinations relating to the appropriateness of payments
• Be able to work in a fast-paced environment, shift objectives, and perform multiple tasks at once
• Be able to work independently and as part of a team, making decisions based on experience and best practices, and collaborating with others
• Have the willingness and ability to do whatever is necessary to accomplish workload demands
• Have experience meeting hard deadlines and delivering high-quality work
• Possess strong attention to detail; investigative and deductive reasoning skills are a must
• Be able to make decisions and conclusions when working with limited information using reference materials and strong problem-solving skills
• Be proficient in using enterprise productivity and communication tools (e.g., Excel, Word, Gmail, Google Sheets, Slack, etc.); intermediate spreadsheet skills are critical, including manipulating spreadsheets, using formulas, working with pivot tables, and running macros within existing spreadsheets (some training provided)
• Be able to receive constructive feedback and maintain a positive attitude; be flexible in dealing with change

Responsibilities

• Be responsible for client growth, including monetary goals, production goals, ideation and development goals, and prioritization of work and workforce allocation
• Participate as an expert in the feedback loop for data, product, and query enhancements
• Work directly with management and clients to plan and prioritize growth initiatives
• Collaborate with management, data science, and product development teams to create more comprehensive queries, pricing, and software solutions
• Constantly develop new auditing concepts using experience and knowledge of the claims payment cycle, contracts, policies, and guidelines
• Conduct comprehensive reviews of pre and post-pay claims using available resources, including claims data, client adjudication systems, payment guidelines, compliance requirements, contracts, pricing systems, medical records, and authorizations
• Serve as a claims billing and payment expert and resource for data teams and other departments
• Develop and refine reimbursement policies and procedures in collaboration with the team
• Remain updated with the latest billing guidelines and regulations
• Achieve the expected level of accuracy and quality set by the client for the auditing concept and for valid claim identification and documentation
• Identify potential claims outside of the concept where additional recoveries may be available. Develop high-quality, high-value concepts and/or process improvement tools
• Meet and/or exceed standard guidelines for production and quality measurements
• Perform all tasks from the basic Jr. Auditor role to leading individuals, and have the ability and desire to take on most any task that promotes the growth of the team, client, and company

Preferred Qualifications

• Have prior management experience in a related field
• Have experience writing healthcare payment policies
• Have experience working with multiple healthcare payers
• Have coding certification

Benefits

• Work from anywhere in the US
• A flexible and trusting environment
• Hardworking and supportive colleagues and a leadership team that understands the importance of recruiting and retaining top talent
• Incredible Medical/Dental/Vision benefits for employees & their families
• Competitive salary and equity, 401(k) sponsorship, life insurance
• Generous Learning and Development Reimbursement policy
• Flexible time off