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.

The Medical Review Audit Supervisor - Clinical leverages their nursing background, deep knowledge of clinical review, and experience leading others to manage staff and operational results for a remote team of nurses and other audit roles, performing clinical review audits. The Supervisor will leverage first-hand experience and knowledge of claims auditing for supporting management with strategy activities such as needs assessments, capacity planning, and ensuring required staffing levels and productivity & quality standards are being achieved consistently.

Key Responsibilities to include:

• Regularly performs limited volume of clinical audits to maintain subject matter expertise, and additionally as needed to support business needs.

• Performs audit quality assurance reviews to supplement QA team activity as necessary based upon business need or special projects.

• Contributes to the resolution of quality review rebuttals.

• May perform appeals review/activity to supplement Appeals team, based upon business need.

• Actively identifies and recommends opportunities for cost savings and improving outcomes that can have a direct impact to the company's profitability.

• Effectively ensures adherence to medical review guidelines and training requirements of staff.

• Supports audit management and segment specialists with activities for new concept implementation

• Supports management with needs assessments and capacity planning

• Monitor and manage inventory of assigned business to ensure timelines are met.

• Use data, reports and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.

• Oversee and review audit determinations to ensure consistency in decision-making.

• Collaborate with other departments to resolve operational problems.

• Proactively monitors and in alignment with applicable management ensures activity required to meet team staffing levels necessary to achieve business objectives.

• Provides support as needed to ensure auditors are equipped with tools and resources required to perform audits.

• Supervise daily activities of clinical audit staff that may include both salaried exempt and hourly employees.

• Provide audit guidance to medical review staff; identify trends and present solutions.

• Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.

• Manages team Time and Attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.

• Collaborates with The People Team for applicable corrective action as applicable.

• Complete and conduct performance reviews for assigned staff.

• Conduct team meetings with direct reports on a regular basis.

• Provide leadership to team members, provide solutions, and resolve conflicts.

• Escalate to management and collaborate with HR as applicable to bring appropriate solutions to employee matters.

• Provide reporting and updates to management as required and appropriate for operational and staff activity and results.

• Participates in and contributes to applicable department meetings.

• May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.

• May support management with activities to monitor inventory and activity of 3rd party/subcontractors.

• Become subject matter expert for assigned business segment(s).

• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.

• May support training material/tools and best practices development.

• Identify needs and ensure team receives necessary training.

• Support training activities for new audit staff or provide supplemental training for existing staff as needed.

• Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.

• Receives feedback and adjusts work priority for self and team as necessary.

• Leads by example and conducts work in accordance with company policies, government regulations and law.

• Perform other incidental and related duties as required and assigned to meet business needs.

Knowledge, Skills and Abilities Needed:

• Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.

• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.

• Proficiency with MCS 1500/UB 04 forms

• Working knowledge of encoder

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.

• Proven ability to review, analyze, and research medical billing, documentation, and coding issues

• Reimbursement policy and/or claims software analyst experience

• Familiarity with interpreting electronic medical records (EHR)

• Willing and able to lead by example, communicate ideas, take initiative and drive the team to achieve organizational goals.

• Experience in developing, documenting and implementing process and procedures.

• Experience in inventory management, resource planning and report generation.

• Skill in analyzing information, identifying trends and presenting solutions.

• Understands inventory management objectives, activities, and key drivers in achieving operational goals.

• Demonstrated ability to consistently apply sound judgment and good effective decision making.

• Excellent communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.

• Demonstrated ability to collaborate effectively in a variety of settings and topics.

• Excellent editing and proofreading skills.

• Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.

• Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.

• Excellent time management and delivers results balancing multiple priorities.

• Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.

• Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.

• Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.

• Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.

• Ability to create documentation outlining findings and/or documenting suggestions.

• Strong general technical skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings.

• Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.

• Ability to be flexible and thrive in a high pace environment with changing priorities.

• Adaptable to applying skills to diverse operational activities to support business needs.

• Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.

• Serves as positive role model, and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.

Required and Preferred Qualifications:

• Current active unrestricted Nursing license in good standing required. Not currently sanctioned or excluded from the Medicare program by OIG, is also required.

• Medical coding certification is a plus.

• 3+ years diverse nursing experience providing direct care in an inpatient or outpatient setting.

• 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company.

• 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. Those who have less than 5 years experience may be considered based upon demonstrated skills and/or formal training and other relevant experiences

• 3+ years relevant supervisory or leadership experience in similar business environment, preferred. Experience managing remote staff is a plus.

• Some Supervisory experience may be required for certain Supervisor roles.

• Prior experience in payer edit development, and/or reimbursement policy experience a plus.

EXPECTED ANNUAL SALARY RANGE: $85,000 - 110,000

Equal Employment Opportunity at Machinify 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. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/