Lead Auditor, Medical Claims

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 Lead Auditor for post pay data mining to conduct claims audits on behalf of Machinify’s customers. In addition, the Lead Auditor will assist in concept ideation, product testing, quality enhancements, and related tasks to ensure customer satisfaction.

The ideal person for this role has an extensive background in healthcare claims auditing, claims processing and coding, and a high level of understanding of payment guidelines for CMS, Medicaid and commercial payers. 

Responsibilities/Impact:

• Develop new auditing concepts by utilizing experience and knowledge of the claims payment cycle, contracts, policies and guidelines

• Conduct comprehensive reviews of post pay claims using any and all available resources. Including but not limited to...claims data and client adjudication systems, payment guidelines and compliance with regulatory requirements, contract, pricing systems, medical records, authorizations, etc.  

• Serve as a resource and expert in claims billing and payment for the data teams and other departments

• Develop and refine reimbursement policies and procedures in collaboration with the team

• Proactively keep up to date with the latest healthcare billing guidelines and regulations

• Achieve the expected level of accuracy and quality set by the client for the auditing concept, for valid claim identification and documentation

• Identifies 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.

• Additional responsibilities as assigned or needed to support the business.
  

Required Skills and Qualifications:

• 10+ years of relative Medical coding and claims auditing experience

• Experienced in analyzing payment information against Medicare and payer billing guidelines to assess the accuracy and appropriateness of payments

• Deliver timely high-quality work within a fast pace and ambiguous environment

• Strong attention to detail; investigative and deductive reasoning skills are a must

• Ability to navigate an autonomous work environment and manage competing priorities

• Must be able to make decisions and conclusions when working with limited information using reference materials and strong problem-solving skills.

• Proficiency in using productivity tools (e.g., Excel, Word, Gmail, Google Sheets, Slack, etc.); intermediate spreadsheet skills level, to include: ability to manipulate a spreadsheet, use formulas, work with pivot tables, run macros within existing spreadsheets; some training provided.

• Certifications in medical coding and billing (CCS, CPC, RHIA, RHIT etc)

Preferred skills:

• Post-pay data mining auditing experience

• Concept/Trend development experience

• Payer auditing experience

What we offer:

• Work from anywhere in the US! Our team is distributed and most of us work from home

• A flexible and trusting environment where you'll feel empowered to do your best work

• 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

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.

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.

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.