Backed by Battery and GV.
About the role
Regularly performs limited volume of clinical audits to maintain subject matter expertise, and additionally as needed to support business needs. Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.
What they're looking for
- Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules
- Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding
- Proficiency with MCS 1500/UB 04 forms
- Working knowledge of encoder
- Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual
- Proven ability to review, analyze, and research medical billing, documentation, and coding issues
More about this role
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.
The Medical Review Audit Supervisor - Clinical leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Supervisor will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.
Regularly performs limited...
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