Audit Policy Analyst, Post-Acute Services
New
M
MachinifyHealthcare payment integrity
Remote - USFull-TimeSenior
Salary not disclosed
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Job Details
- Experience
- Minimum 5+ years of progressive experience in DME, home health, and/or home infusion therapy, including direct experience in payment integrity, claims auditing, or provider-side billing and compliance. Equivalent experience of 3+ years in post-acute claims auditing and recovery auditing.
- Required Skills
- Microsoft Excel
Requirements
- Hold a bachelor's degree in nursing, health administration, business, or a related field, or have equivalent experience.
- Have at least 5 years of progressive experience in DME, home health, and/or home infusion therapy, including payment integrity, claims auditing, or provider-side billing and compliance; alternatively, have at least 3 years in post-acute claims auditing and recovery auditing.
- Hold a Registered Nurse or nationally recognized coding credential, such as RHIA, RHIT, AHIMA, AAPC, or equivalent.
- Bring knowledge of post-acute coding and payment methodologies, including ICD-10-CM, HCPCS Level II, CPT, HIPPS, DME fee schedules, Competitive Bidding, Home Health PPS under PDGM, and the Medicare home infusion therapy benefit.
- Understand DME MAC jurisdictions, LCDs, Policy Articles, and supplier documentation requirements.
- Understand Medicare home health conditions of payment, including homebound status, face-to-face encounters, certification and recertification, plans of care, OASIS assessments, and Notices of Admission.
- Have experience with data utilization and statistical analysis for audit concept scoring and selection.
- Have experience developing clinical content, policy documentation, and training resources.
- Be proficient in Microsoft Office, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams; advanced Excel and PowerPoint skills are specified.
- Be familiar with encoder and grouper applications, including the Home Health PDGM Grouper.
- Be able to manage concurrent workflows independently and deliver results on time in a remote environment.
- Home health coding, OASIS, or infusion nursing credentials are preferred.
Responsibilities
- Develop post-acute audit concepts for DME, home health, and home infusion claims, including research, claim analysis, rule documents, and code lists.
- Review and update audit concepts in response to periodic cycles, client changes, and regulatory changes.
- Monitor and interpret CMS coverage determinations, policy articles, manuals, and transmittals, and document their impact on concepts.
- Perform quality reviews and validate audit logic against post-acute billing rules, coding guidelines, payment methodologies, and payer policy.
- Identify concept performance discrepancies and coordinate resolution with clinical, coding, and operations teams.
- Manage concurrent audit concept workflows and support consistent policy application across audit platforms and client programs.
- Create training materials, job aids, reference tools, and documentation for post-acute audit concepts.
- Respond to client inquiries and support presentations, provider disputes, and escalations involving post-acute claims.
- Analyze concept performance and claim data to identify trends and recommend actions to optimize audit yield and accuracy.
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