Senior Drg Audit Sme

Summary

Join Machinify, a leading provider of AI-powered healthcare software, as a Senior DRG Audit Subject Matter Expert. You will conduct comprehensive DRG validation audits of medical records, ensuring accurate coding and regulatory compliance. This role requires expertise in inpatient coding, DRG payment systems, and medical claims billing. You will serve as a coding expert, develop coding policies, and assist with audits, edits, denials, and reporting. Machinify offers a flexible work environment, remote work options, competitive salary and equity, and excellent benefits.

Requirements

• 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
• RHIA or RHIT
• 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)
• Experience developing audit selection criteria to identify DRG coding errors and overpayments
• 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
• Proficiency in the use of EMR’s and encoders

Responsibilities

• Conduct comprehensive DRG validation 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; ensuring that information is accurate and current, meeting professional coding standards
• Develop and refine coding policies and procedures in collaboration with the HIM team
• Quality Review - Monitors and audits inpatient and/or outpatient client accounts across the system, looking at facility coding for inpatient and/or outpatient accounts. Performs annual performance, randomized and quality assurance reviews to assess comprehension of training efforts. Also assists other external and regulatory audits
• Edits/Denials/Coding - Assists with edits, denials and appeals
• Reporting - Assists with the creation of various documents and reports as requested. Immediately provides reports related to compliance risks when requested
• Payment integrity- Assists with other audit types as needed in support of product, audit opportunities, and concept development
• 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/Overpayment Opportunities. 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

Preferred Qualifications

Inpatient Coding Credential - CCS or CIC

Benefits

• 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
• Excellent healthcare, flexible time off, and other benefits and perks to meet the needs of each individual