Machinify - IBR Policy and Content Development Analyst
Requirements
• 3+ years’ experience performing payment integrity or auditing facility claims. • Experience translating complex medical regulations and payer guidelines into clear, legally compliant clinical content and structured policy documentation. • Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems. • Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology. • Knowledge of national coding standards, particularly payment rules. • Strong organizational and written communication skills. • In-depth knowledge of diverse facility reimbursement methodologies and commercial/government payment policies to ensure accurate contract compliance and audit integrity. • Proficient in Windows office systems, including the full Microsoft Suits (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams). • Demonstrated experience or proficiency in utilizing AI tools and automation platforms to optimize clinical research. • Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with clients. • Ability to prioritize and multitask. • License/Certification • RHIA, RHIT, CCS, CPC, CPMA • Or, Active RN/LPN License
Responsibilities
• Review and update existing audit concepts on required regular cycles or in response to client or regulatory changes, including research, data/claim analysis, and updates to rule documents and code lists. • Conduct research and analysis to identify the impact of regulatory, coding, or payer policy changes on existing concepts and document findings accordingly. • Interpret and apply client-specific payer policy in audit concept reviews and updates. • Research, interpret, and embed state-specific Medicare/Medicaid provider manuals and regional regulatory mandates into audit concept configurations. • Evaluate payer policies to proactively identify gaps and propose new, audit concepts to clients. • Ensure audit concepts are appropriately formulated across offering types and program lines (Medicaid, Medicare, Commercial). • Align concepts with industry standards, including CMS, MUEs, and CPT/HCPCS coding guidelines. • Develop, validate, and maintain audit concepts targeting coding unbundling in accordance with NCCI edits. • Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams. • Benchmark concept outcomes against industry standards, historical data, and client baselines to identify gaps and optimization areas. • Participate in testing for new concepts to verify that the automated logic performs accurately in the system environment before implementation. • Confirm audit concepts are validated against current coding guidelines, payment methodologies, and payer policy prior to deployment. • Ensure consistent and correct application of policies across platforms and client programs by the audit teams. • Collaborate with cross-functional teams to develop clinical and coding solutions, audit strategies, and payment integrity initiatives and policies. • Identify opportunities to improve audit concept workflows and documentation processes. • Support ongoing enhancements to concept tracking and cross-function coordination. • Leverage AI tools and automation to optimize policy development, streamline research, and scale payment integrity solution performance. • Perform additional responsibilities and ad hoc projects as assigned to meet business needs.
Benefits
• This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location. • Work from anywhere in the US! Machinify is digital-first. • Top Medical/Dental/Vision offerings • 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 • Equal Employment Opportunity at Machinify • We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual 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/
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