Audit Policy Analyst – Post-Acute Services

🔥 1 minute ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🧐 Analyst

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 $10M Series A - Machinify on 2018-10

Healthcare • Consulting • Logistics

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Serve as the subject matter expert for DME, home health, and home infusion therapy claims across government and commercial lines of business. • Develop, maintain, test, and optimize post-acute payment integrity audit concepts. • Partner with operations, clinical, client services, and technology teams to align concepts with coding standards, coverage and medical necessity criteria, documentation requirements, and payer policy. • Develop new audit concepts through research, data and claim analysis, rule documents, and code lists. • Review and update audit concepts based on periodic cycles, client changes, regulatory changes, HCPCS updates, DMEPOS fee schedules, and Home Health PPS final rules. • Monitor and interpret NCDs, DME MAC LCDs and Policy Articles, Medicare manuals, and CMS transmittals. • Interpret and apply commercial and Medicaid payer policies across multiple states and managed care contracts. • Perform QA reviews and validate audit logic against post-acute billing rules and coding guidelines. • Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams. • Manage multiple concurrent audit concept workflows and ensure timely, accurate delivery. • Serve as escalation point for complex DMEPOS, home health, and home infusion documentation and coverage questions. • Create training materials, job aids, reference tools, and documentation checklists. • Respond to client inquiries and support presentations, provider disputes, and escalations. • Monitor concept performance, conduct statistical analysis, identify claim-data trends, and recommend actions to optimize audit yield and accuracy. • Improve audit workflows, documentation processes, concept tracking, QA processes, and cross-functional coordination. • Perform additional responsibilities and ad hoc projects as assigned.

🎯 Requirements

• Bachelor's degree in nursing, health administration, business, or a related field, or equivalent experience. • Minimum 5+ years of progressive experience in DME, home health, and/or home infusion therapy, including direct experience in payment integrity, claims auditing, or provider-side billing and compliance. • Equivalent experience of 3+ years in post-acute claims auditing and recovery auditing. • Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required. • Home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI) credential preferred. • Demonstrated depth and breadth of knowledge across ICD-10-CM, HCPCS Level II, CPT, HIPPS, DME fee schedule, Competitive Bidding Program, Home Health PPS under PDGM, and Medicare home infusion therapy benefit. • Deep understanding of DME MAC jurisdictions, LCDs, Policy Articles, supplier documentation requirements, Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and DME Required Prior Authorization List. • Deep understanding of Medicare home health conditions of payment, including homebound status, face-to-face encounter, certification and recertification, plan of care, OASIS assessment, and Notice of Admission. • Broad knowledge of provider billing guidelines, payer reimbursement policies, medical necessity criteria, and claim adjudication standards for post-acute services. • Expert knowledge of clinical documentation requirements and audit concept development for post-acute claim types. • Strong experience in data utilization and statistical analysis, including driving scoring and selection for audit concepts. • Progressive healthcare data analysis experience and experience gathering and documenting requirements for projects of diverse scope and complexity. • Experience developing clinical content, policy documentation, and training resources. • Effective communication with organizational levels, diverse teams, and external clients. • Exceptional written and verbal communication skills with strong attention to detail. • Excellent critical thinking and analytical skills. • Ability to manage multiple concurrent workflows independently in a remote environment and deliver results on time. • Proficiency in Windows office systems and the full Microsoft Suite, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams. • Advanced Microsoft Office skills, particularly Excel and PowerPoint. • Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper. • Experience working with various software platforms and collaborating with development teams. • Proven success in a remote working environment.

🏖️ Benefits

• Remote working environment • Employment at will • Equal employment opportunity • Reasonable accommodation during the application or recruitment process