DRG Reviewer

Experience Required

2 - 20 years

Minimum Education Required

Bachelor's Degree

Compensation

$90,000.00 - $115,000.00 / yearly

Hours Per Week

40

Number Of Positions

1

Work Schedule and Shift Requirements

First (Day)

Job Description

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. 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.

About the Opportunity

As part of the Complex Payment Solutions Team, you will, as a DRG Reviewer, be a key contributor responsible for conducting thorough DRG payment validation reviews, including clinical and coding assessments, of medical records and related documentation in accordance with contract-specific review criteria. This position requires an in-depth understanding of clinical guidelines, coding protocols, and regulatory requirements to ensure accurate payment determinations.

In this role, you will meticulously document findings, provide detailed clinical, policy, and regulatory support and collaborate with relevant stakeholders to ensure compliance with payment standards. Your expertise will be critical in ensuring that payment decisions are supported by accurate and complete documentation, ultimately contributing to the integrity and efficiency of the payment process.

What you'll do

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.

What you bring (Role Requirements)

Education 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.

Certification (at least one of the following is required):

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

Qualifications:

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.

What We Offer:

Workfrom anywhere in the US!Machinifyis 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

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications,etc.We are hiring fordifferent levels, and our Recruiting team will let you know if you qualify for a different role/range.Salary is onecomponentof the total compensation package, which includes meaningful equity, excellent healthcare, flexible time off, and other benefits andperks.

Pay range: $90,000 - $115,000, plus quarterly bonus.

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of r ace, color, ancestry, r eligion, s ex, national origin, s exual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at:https://www.machinify.com/candidate-privacy-notice/

Equal Opportunity Employer

Veteran Friendly Employer

Job Type

Full time

Benefits Offered

Not specified

Veteran Preference

No

Place of Work

On-site

Requisition ID

4108241009