Lead Auditor

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 claims billing and payment expert, and resource for the 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 .

• 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.

• Meet and/or exceed standard guidelines for production and quality measurements.

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

Required Skills and Qualifications:

• 10+ years of relative experience.

• Ability to review payment information against Medicare and payer billing guidelines to make determinations relating to the appropriateness of payments.

• Experience or certification in coding/billing is helpful.

• Ability to meet deadlines.

• Ability to work independently and as part of a team.

• Delivery of high-quality work is critical.

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

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

• Must be proficient in using enterprise productivity and communication 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.

Preferred skills (but not required to apply):

• Post-pay data mining auditing experience

• Concept/Trend development experience

• Payer auditing experience

• Coding certification

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

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.