DRG Dispute Reviewer

🔥 6 minutes ago

🇺🇸 United States – Remote

💵 $100k - $115k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

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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

• Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations • Review inpatient medical records, UB-04s, and documentation for correct DRG assignment and compliance with coding, billing, and payment guidelines • Apply clinical validation and coding principles using MS-DRG and APR-DRG grouping logic • Prepare clear, concise, evidence-based rationales for clients, providers, or payers • Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates • Assess medical necessity, documentation sufficiency, and code assignment accuracy • Collaborate with audit leads and team members on dispute resolution quality and consistency • Meet accuracy, timeliness, and productivity standards • Adhere to HIPAA guidelines, industry best practices, and AHIMA’s Standards of Ethical Coding • Participate in client meetings and present audit results when required • Use proprietary audit platforms, encoders, and medical record systems • Perform additional tasks supporting audit operations and client needs

🎯 Requirements

• An associate or bachelor’s degree in nursing (active/unrestricted license), or in health information management is required • Work experience may be considered in lieu of formal education at leadership discretion • At least one required certification: RHIA, RHIT, CCS, CIC, CDIP, or CCDS • Minimum 3 years of inpatient hospital coding (IPPS reimbursement) • Minimum 4 years DRG validation (clinical and coding) • Expert-level knowledge of ICD-10-CM/PCS coding systems, MS-DRG/APR-DRG methodologies, and official guidelines • Strong analytical and critical thinking skills for complex case reviews • Ability to write clear, professional rationales supported by clinical and coding evidence • High attention to detail, accuracy, and compliance • Able to work independently with minimal supervision in a remote environment • Technical proficiency with medical record systems and audit platforms • Technical proficiency with encoder/grouper tools such as TruCode and 3M • Proficiency with Microsoft Office Suite, including Excel, Word, Outlook, and Teams • Experience in DRG dispute reviews, clinical validation, and recovery audits strongly preferred • Prior experience in inpatient clinical documentation integrity (CDI) is a plus

🏖️ Benefits

• Work from anywhere in the US • Top Medical/Dental/Vision offerings • FSA/HSA • Tuition reimbursement • Competitive salary • 401(k) with company match • Additional health and wellness benefits and perks • Flexible and trusting environment where you’ll feel empowered to do your best work • Eligibility for quarterly bonuses

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