Senior Clinical Audit Subject Matter Expert

The Senior Clinical Audit Subject Matter Expert at Machinify is primarily responsible for conducting detailed Clinical DRG validation audits to ensure compliance with payer policies and regulatory standards. Additionally, this role involves performing audits related to Readmission and Medical Necessity determinations, as well as providing clinical expertise to support product development. The SME also collaborates closely with various teams to refine clinical policies, manage quality assessments, and suggest improvements within the audit platform.

To qualify for the Senior Clinical Audit Subject Matter Expert role at Machinify, candidates are expected to possess an Associate or Bachelor's degree in Nursing along with at least 10 years of relevant experience in claims auditing or quality assurance. Additional certifications such as RHIA or RHIT, along with a CDIP or CCDS, are required, while CCS or CIC credentials and active nursing licensure are preferred. Experience with various coding systems and audit selection criteria development is also critical.

Clinical experience is extremely important for a Senior Clinical Audit Subject Matter Expert at Machinify. Candidates should have at least 5-10 years of nursing experience in a facility setting, and experience in documentation improvement or leading such teams. This background enables SMEs to effectively assess medical necessity and manage quality audits, ensuring high accuracy and adherence to guidelines.

Essential skills for the Senior Clinical Audit Subject Matter Expert role at Machinify include excellent written and verbal communication, proficiency in Electronic Medical Records (EMR), Interqual/MCG, and encoders, and a comprehensive understanding of medical claims billing and coding terminology. Additionally, familiarity with reimbursement policies and compliance guidelines is crucial for ensuring the quality and accuracy of audit outcomes.

At Machinify, we are committed to fostering an inclusive work environment that promotes personal and professional growth. For the Senior Clinical Audit Subject Matter Expert, we provide resources for ongoing training and education, encourage collaboration among diverse teams, and offer opportunities to contribute insights that drive product enhancements. We celebrate unique backgrounds and perspectives, which enrich our workplace and create better solutions for the healthcare industry.

In responding to this question, provide specific examples of your past work with clinical validation audits. Illustrate how you assessed compliance with payer policies and regulatory requirements. Highlight the impact that your audits had on the quality of care or reimbursement processes, demonstrating your understanding of their critical role in healthcare.

Discuss the frameworks and guidelines you employ, such as utilizing payer policies and clinical practice standards. Mention how you ensure thorough documentation and adherence to compliance requirements during these reviews, showcasing your systematic approach to maintaining high-quality audit standards.

Convey your commitment to professional development by mentioning specific sources such as professional organizations, continuing education programs, and industry publications. Highlight experiences from attending conferences or participating in training that keep you well-informed about the latest trends and requirements in the healthcare auditing landscape.

Provide a concrete example that emphasizes your problem-solving skills. Describe the challenge, your thought process, and the strategies you implemented to overcome it. This allows you to demonstrate critical thinking and resilience, two vital qualities for a Senior Clinical Audit Subject Matter Expert.

Emphasize the importance of collaboration in achieving accurate audit outcomes. Discuss how working alongside product developers, engineers, and healthcare professionals leads to enhanced strategies and efficient problem-solving, ensuring compliance and quality throughout the auditing process.

Illustrate your perspective by discussing how you integrate audit findings and clinical insights into product enhancements. Touch on any tools or features you believe could be valuable in improving the auditing process, showing that you think critically about the intersection between auditing and product development.

Share your familiarity with specific EMR systems and how you've utilized them to enhance data retrieval, streamline documentation, and ensure compliance within auditing practices. Highlight how your proficiency contributes to efficiency and accuracy in audits.

Demonstrate your depth of knowledge regarding reimbursement guidelines by explaining how these systems impact clinical audits and patient care. Share insights on how understanding these concepts informs your auditing strategies and helps ensure compliance with payer policies.

Detail your approach to assessing audit performance, such as conducting quality assurance reviews and soliciting feedback from team members. Illustrate how these strategies lead to targeted training initiatives that elevate the overall quality of audits.

Articulate your passion for enhancing healthcare systems and improving outcomes through auditing. Explain how the opportunity to contribute valuable insights, drive quality improvements, and collaborate with a talented team at Machinify excites you and fuels your motivation to succeed.