DRG Reviewer

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $90k - $115k / year

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

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

Healthcare Insurance • Artificial Intelligence • SaaS

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

• Audit patient medical records using clinical, coding, and payer guidelines to ensure accurate reimbursement. • Provide clear, evidence-based rationale for code recommendations or reconsiderations to providers or payers. • Collaborate with team leaders to ensure thorough review of DRG denials. • Conduct audits in alignment with organizational quality and timeliness standards. • Use proprietary auditing systems proficiently to make consistent determinations and generate audit letters. • Recommend improvements to the audit system to enhance efficiency. • Ensure compliance with HIPAA regulations for protected health information. • Perform other duties as assigned.

🎯 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. • RHIA - Registered Health Information Administrator • RHIT- Registered Health Information Technician • CCDS - Certified Clinical Documentation Specialist • CDIP - Clinical Documentation Improvement Practitioner • CCS - Certified Coding Specialist • CIC - Certified Inpatient Coder • Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more required • Strong focus on quality and attention to detail. • Deep curiosity and analytical skills to understand root causes of events and behaviors. • Proven ability to apply critical judgment in clinical and coding determinations. • In-depth knowledge of clinical criteria and documentation requirements to support code assignments. • Expert in DRG methodologies (e.g., MS & APR). • Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines. • Ability to work independently and efficiently with minimal supervision.

🏖️ Benefits

• Work from anywhere in the US! Machinify is digital-first. • Top Medical/Dental/Vision offerings • FSA/HSA • Tuition reimbursement • Competitive salary, 401(k) with company match • PTO • Additional health and wellness benefits and perks • Flexible and trusting environment where you’ll feel empowered to do your best work