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.

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.

) Education

: 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.

to support code assignments. , 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 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.

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.

What We Offer

: Work from anywhere in the US! Machinify is digital-first.

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, ce