Healthcare Audit Policy Analyst
M
MachinifyHealthcare Intelligence
Work from anywhere in the US!Full-TimeMiddle
Salary80,000 - 120,000 USD per year
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Job Details
- Experience
- Minimum 5+ years of progressive experience in healthcare claim type subject matter specialty; 3+ years in claims auditing and recovery auditing.
- Required Skills
- Data AnalysisMicrosoft Excel
Requirements
- Bachelor's degree in health administration, business, nursing, or related field.
- Minimum 5+ years of progressive experience in healthcare claim type subject matter specialty.
- Minimum 3+ years in claims auditing and recovery auditing.
- Registered Nurse or Certified Coder (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.
- Depth of knowledge in ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and HIPPS coding systems.
- Expertise in MS-DRG, APR-DRG, APC, APG, PDPM, and PDGM payment methodologies.
- Understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
- Experience in data utilization, statistical analysis, and driving scoring for audit concepts.
- Proficiency in Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, Teams).
- Familiarity with multiple encoder/grouper applications.
- Proven success managing concurrent workflows independently in a remote environment.
Responsibilities
- Review and update existing audit concepts periodically or in response to regulatory and policy changes.
- Perform research and data analysis to identify impacts of policy updates on audit concepts.
- Formulate audit concepts across Data Mining and Complex Audit programs for CMS, Medicaid, and Commercial lines.
- Conduct QA reviews of concepts to ensure compliance with coding guidelines and payer policies prior to deployment.
- Manage concurrent audit concept workflows and track progress with high accuracy.
- Develop training materials, reference tools, and maintain policy documentation.
- Partner with clinical, operations, and technology teams to drive concept quality and provide subject matter support.
- Monitor concept performance through statistical analysis to optimize audit yield.
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