Senior Clinical Audit Subject Matter Expert

Summary

Join Machinify, a leader in AI-powered healthcare claims software, as a Senior Clinical Audit Subject Matter Expert (SME). You will drive quality testing and enhancements of our payment integrity audit product. This role requires extensive experience in facility-based nursing, clinical documentation improvement, and clinical validation audits. Deep understanding of reimbursement guidelines (Interqual/MCG, MS-DRG, APR-DRG) is crucial. You will conduct audits, serve as a clinical expert, develop clinical policies, and perform quality assessments. The ideal candidate possesses strong communication skills and proficiency with EMRs and relevant software.

Requirements

• Possess an Associate's or Bachelor's degree in Nursing
• Have 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
• Hold RHIA or RHIT certification
• Hold CDIP or CCDS certification
• Possess current RN licensure
• Have 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
• Have 5-10 years nursing experience in a facility setting
• Have 5-10 years experience performing documentation improvement or leading documentation improvement teams
• Have experience developing audit selection criteria
• Demonstrate adherence to payer, CMS and other regulatory compliance guidelines and mandates
• Possess working knowledge of applicable industry-based standards
• Possess excellent written and verbal communication skills
• Demonstrate proficiency in the use of EMR’s, Interqual/MCG, and encoders

Responsibilities

• 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

Preferred Qualifications

Hold an Inpatient Coding Credential - CCS or CIC