DRG Coding Validation Specialist

Who We Are

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 60 health plans, including many of the top 20, and representing more than 160 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.

Location: This role is full remote

About the Opportunity

At Machinify, we're constantly reimagining what's possible in our industry-creating disruptively simple, powerfully clear ways to maximize our clients' financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Payment Solutions Team, as a DRG Coding Validation Specialist, you will conduct thorough reviews of provider medical records to validate the accuracy of ICD-10/PCS coding and ensure the correct assignment of Diagnosis-Related Groups (DRG). This role involves applying customer-specific payment policies, ensuring compliance with regulatory requirements, and supporting accurate reimbursement practices. The specialist works collaboratively with healthcare providers and internal teams to uphold coding quality standards, identify potential coding discrepancies, and provide detailed rationales for adjustments. By maintaining expertise in coding guidelines and industry standards, this position plays a vital role in safeguarding data integrity and optimizing financial outcomes.

What you'll do

• Conduct data quality reviews of inpatient medical records to verify ICD-10/PCS codes and DRG/APR DRG accuracy.
• Maintain expertise in ICD-10/PCS coding conventions, Official Coding Guidelines, and AHA Coding Clinic.
• Apply customer-specific payment policies.
• Validate patient data by reconciling claims with medical records.
• Provide written rationale for coding changes affecting DRG assignments, citing official guidelines and conventions.
• Identify and audit high-risk cases for potential errors.
• Attend team meetings and training sessions as required.
• Utilize computer applications, DRG Grouper/Pricer software, and ICD-10-CM encoder software.
• Adhere to AHIMA Standards of Ethical Coding.

Certifications: (minimum of 1 of the following coding credentials required)

• Registered Health Information Administrator (RHIA),
• Registered Health Information Technician (RHIT),
• Certified Coding Specialist (CCS), CCS-P AHIMA

• National certification: RHIA, RHIT, or CCS.
• At least 5 years of hospital inpatient coding for PPS reimbursement or 2+ years in DRG validation.
• Strong oral and written communication skills.
• In-depth knowledge of DRG structure and regulatory standards.
• Must meet or exceed acceptable active time on system expectations during set business hours within the employee's time zone.

What Success Looks Like...

After 3 months

You will have a strong understanding of the role.

You begin building relationships and collaborating with peers.

You develop effective time and priorities management.

You receive initial feedback about your performance and are using it to improve.

You've gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.

You have established a strong network of internal relationships and are recognized as a key collaborator.

You've been entrusted with greater responsibility indicating the company's confidence in your abilities.

You see opportunities for career progression and personal development.

Pay range: $73,000-$105,000 USD

This is an exempt position. The salary range is for Base Salary.Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

At Machinify, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative, accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, Machinify is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer.

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