Backed by Battery and GV.
About the role
As part of the Complex Payment Solutions Team, the Concept Development Analyst applies subject matter expertise across government and commercial healthcare claim types to lead the development, maintenance, testing, and optimization of payment integrity audit concepts.
What they're looking for
- Bachelor's degree in health administration, business, nursing, or a related field, or equivalent experience
- Minimum 5+ years of progressive experience in healthcare claim type subject matter specialty, including direct experience in payment integrity and claims auditing
- Equivalent experience of 3+ years in claims auditing and recovery auditing
- Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required
- Demonstrated depth and breadth of knowledge across payment integrity elements, including: ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and HIPPS coding systems and MS-DRG, APR-DRG, APC, APG, PDPM, and PDGM payment methodologies
- Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems
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.
As part of the Complex Payment Solutions Team, the Concept Development Analyst applies subject matter expertise across government and commercial healthcare claim types to lead the development, maintenance, testing, and optimization of payment integrity audit concepts. This role works closely with cross-functional teams — including operations, clinical, client services, and technology — to ensure audit concepts are accurately built, validated, and maintained in alignment with coding standards, medical necessity criteria, regulatory requirements, and client-specific payer...
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