Data Mining Auditor

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.

Machinify is seeking an Auditor for pre and/or post pay data mining to conduct claims audits on behalf of Machinify’s customers. In addition, the Auditor will assist in product testing, quality enhancements, and related tasks to ensure customer satisfaction.

The ideal person for this role has a strong background in healthcare claims auditing, claims processing and coding, and a high level of understanding of payment guidelines for CMS and commercial payers.

• Conduct comprehensive reviews of pre and post pay claims using any and all available resources, including but not limited to, claims data and client adjudication systems, payment guidelines and compliance with regulatory requirements, contract, pricing systems, medical records, authorizations, etc.
• Serve as a claims billing and payment expert, and resource for the data teams and other departments.
• Develop and refine reimbursement policies and procedures in collaboration with the team.
• Remain updated with the latest billing guidelines and regulations.
• Achieve the expected level of accuracy and quality set by the audit for the auditing concept, for valid claim identification and documentation.
• Additional responsibilities as assigned or needed to support the business.

• 3-5 years of relative experience.
• Ability to review payment information against Medicare and payer billing guidelines to make determinations relating to the appropriateness of payments.
• Experience or certification in coding/billing is helpful.
• Ability to meet deadlines.
• Willingness and ability to do whatever is necessary to accomplish workload demands
• Delivery of high-quality work is critical.
• Strong attention to detail; investigative and deductive reasoning skills are a must.
• Must be able to make decisions and conclusions when working with limited information using reference materials and strong problem-solving skills.
• Must be proficient in Excel, Word, Gmail, Google Sheets, Slack, etc.
• Able to work in a fast-paced environment and adapt to rapid change and growth.

Preferred Experience:

• Post-Pay data mining auditing experience
• Pre-Pay data mining experience
• Payer auditing experience