Senior Clinical Audit Subject Matter Expert (SME) - Remote

Overview

Machinify is seeking a Senior Clinical Audit Subject Matter Expert (SME) to drive quality testing and enhancement of our product in the payment integrity Audits space.

In Short

• Conduct comprehensive Clinical DRG validation audits of inpatient medical records.
• Perform Readmission and Medical Necessity determination reviews.
• Serve as a clinical expert and resource for product development teams.
• Develop and refine clinical policies in collaboration with the HIM team.
• Perform quality assessments by monitoring client accounts.
• Conduct annual performance and quality assurance reviews.
• Assist with edits, denials, and appeals.
• Create documents and reports as requested.
• Remain updated with clinical guidelines and regulatory requirements.
• Identify potential claims for additional recoveries.

Requirements

• Associates or Bachelor's degree in Nursing.
• 10+ years of experience in claims auditing or quality assurance.
• Certifications: RHIA or RHIT, CDIP or CCDS required.
• Experience with ICD-10CM, MS-DRG, and APR-DRG.
• Excellent written and verbal communication skills.
• Proficiency in EMR’s, Interqual/MCG, and encoders.

Benefits

• Opportunity to work in a leading AI-powered healthcare company.
• Collaborate with a team of experts in the field.
• Engage in impactful work that enhances healthcare processes.
• Flexible working environment.
• Continuous learning and professional development opportunities.