DRG Reviewer; Onsite

Overview

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering value, transparency, and efficiency to health plan clients across the country. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs. This role is onsite in Nashville, TN.

• Claims Review:
  Audit patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.
• Written Communication:
  Provide clear, concise rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.
• Collaboration:
  
  Work with team leaders to ensure DRG denial is thoroughly reviewed.
• Coding Knowledge:
  Maintain expert knowledge of ICD-10-CM/PCS coding conventions and rules, Official Coding Guidelines and AHA Coding Clinic.
• Quality and Time Management:
  Conduct audits in line with organizational quality and timeliness standards; meet productivity requirements.
• Technically savvy:
  Use multiple tools, provider systems, and different medical records systems to perform audits in a timely and comprehensive manner.
• Proficiency:
  Utilize proprietary auditing systems with a high level of proficiency to make sound audit determinations and rationales.
• HIPAA Compliance:
  Ensure HIPAA compliance for protected health information.
• Presentation
  
  Skills:
  
  Participate in exit interviews with the client summarizing audit findings, varying by client/facility.
• Practice Standards:
  Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Other duties as assigned.

• National certification as RHIA, RHIT, and/or CCS.
• Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years’ DRG validation experience.
• Previous auditing/recovery experience preferred.
• Excellent oral and written communication skills.
• Comprehensive knowledge of DRG structure and regulatory requirements.

• Associate or bachelor’s degree in nursing (active/unrestricted license); or
• Associate or bachelor’s degree in health information management; or
• Work experience may be considered in lieu of formal education at leadership discretion.

• RHIA, RHIT, CCS, CCDS, CDIP, CPC-H, or CIC (inpatient coder).

• Inpatient claims auditing, QA or recovery auditing experience of 2+ years.
• Inpatient Clinical Documentation Integrity experience of 2+ years.
• Strong attention to detail and ability to understand root causes of events and behaviors.
• Ability to apply critical judgment to clinical and/or coding determinations.
• Subject matter expert in DRG methodologies (e.g., MS & APR).
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA Coding Clinic Guidelines.
• Ability to work efficiently with minimal supervision.

• Experience with laptops and multiple monitors; remote work experience.
• Proficiency with Windows/Microsoft Office Suite and Teams.
• Experience with encoder/grouper tools (e.g., Tru Code/3M) and/or similar coding/auditing tools.

• Ability to sit/stand for long periods; occasional stooping and reaching; may lift up to 25 pounds; normal vision and hearing; travel to multiple locations within commutable distance.

Pay range: $90,000-$110,000
. This is an exempt position. Salary ranges are base salary and may be influenced by skill set, experience, and geographic location.

• PTO, paid holidays, and volunteer days.
• Health, vision, and dental coverage; 401(k) with company match; flexible spending accounts.
• Tuition reimbursement; company-paid life insurance and disability; parental leave.
• Remote and hybrid work options.

• Ask why;
  Think big;
  Be humble;
  Optimize for customer impact;
  Deliver results.

We are committed to equal employment opportunity and operate as an equal opportunity workplace. We participate in E-Verify where required and do not inquire about salary history in recruitment. Reasonable accommodations are available upon request to our People Operations team.