Audit Policy Analyst, Post-Acute Services
Key Skills for This Role
Full Job Posting
Education and Experience
- Bachelor's degree in nursing, health administration, business, or a related field, or equivalent 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.
- Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.
- Home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI) credential preferred.
- Knowledge, Skills, and Expertise
- Demonstrated depth and breadth of knowledge across post-acute coding systems and payment methodologies, including ICD-10-CM, HCPCS Level II, CPT, and HIPPS, the DME fee schedule and Competitive Bidding Program, Home Health PPS under PDGM, and the Medicare home infusion therapy benefit.
- Deep understanding of DME MAC jurisdictions, LCDs, Policy Articles, and supplier documentation requirements, including Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and the DME Required Prior Authorization List.
- Deep understanding of Medicare home health conditions of payment, including homebound status, face-to-face encounter, certification and recertification, plan of care, OASIS assessment, and the Notice of Admission.
- Broad knowledge of provider billing guidelines, payer reimbursement policies, medical necessity criteria, and claim adjudication standards for post-acute services.
- Expert knowledge of clinical documentation requirements and audit concept development for post-acute claim types.
- Strong experience in data utilization and statistical analysis, including driving scoring and selection for audit concepts.
- Progressive healthcare data analysis experience, including gathering and documenting requirements for projects of diverse scope and complexity.
- Experience developing clinical content, policy documentation, and training resources.
- Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with external clients.
- Exceptional written and verbal communication skills with strong attention to detail.
- Excellent critical thinking and analytical skills.
- Demonstrated ability to manage multiple concurrent workflows independently and in a remote environment, delivering results on time.
- Computer Equipment and Software
- Proficient in Windows office systems, including the full Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
- Advanced skills in Microsoft Office, particularly Excel and PowerPoint.
- Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper.
- Experience working with various software platforms and collaborating with development teams.
- Proven success in a remote working environment.
- 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/
Preferred Qualifications
- Home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI) credential preferred.
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