operations
Posted 3 days agoSupervisor, Outpatient Audit Operations
at Machinify
United StatesHybrid
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Responsibilities
- Optimize for customer impact Deliver results
Requirements
- 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.
- experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.
- Ensures team is executing accurate application of CPT/HCPCS Level II coding in the outpatient setting, with proficiency in modifier usage, National Correct Coding Initiative (NCCI) edits, and Outpatient Code Editor (OCE) logic.
- Provides support as needed to ensure auditors are equipped with the tools and resources required to perform outpatient coding audits effectively.
- Maintains current knowledge of changes that affect the industry and clients as they pertain to outpatient coding practice, CMS OPPS final rules, APG reimbursement updates, regulatory changes, and business trends.
- Comprehensive knowledge of the CMS Outpatient Prospective Payment System (OPPS) including APC grouping logic, status indicators, packaging rules, composite APCs, and pass-through payments.
- Strong working knowledge of Ambulatory Patient Groups (APG) methodology, including APG weight assignment, significant procedure logic, medical visit consolidation, and ancillary packaging.
- Proficiency in CPT/HCPCS Level II coding for outpatient facility services, including correct modifier application.
- Working knowledge of the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs), and Outpatient Code Editor (OCE) logic.
- Familiarity with Ambulatory Surgical Center (ASC) payment system and APC-based ASC grouping as it relates to outpatient coding audits.
- Knowledge of observation services, two-midnight rule implications, and the relationship between observation status and outpatient OPPS billing.
- Understanding of revenue codes and UB-04 claim form completion
- Strong knowledge of ICD-10-CM coding as applied to outpatient encounters, including first-listed diagnosis selection, symptom/sign coding conventions, and POA indicator requirements.
- Familiarity with CMS, Medicaid, and Commercial payer coverage and payment rules for outpatient services, including LCD/NCD applicability.
- Demonstrated ability to successfully develop, lead, and motivate a remote team to high performance; effectively provides constructive feedback and coaching for successful outcomes. •
- Experience in developing, documenting, and implementing outpatient coding audit processes and procedures.
- Skill in analyzing information, identifying coding, and billing trends, and presenting actionable solutions to leadership.
- Experience with inventory management, resource planning, and report generation in a coding audit environment.
- Reimbursement policy and/or claims software experience; proficiency with encoder tools (e.g., 3M, Optum/Ingenix, or equivalent).
- Familiarity with interpreting electronic medical records (EHR) in the context of outpatient coding and medical necessity review. General Skills
- Excellent communication skills, both verbal and written; ability to communicate effectively at all levels within the organization and with external clients.
- Strong general technical skills including MS Office applications (Intermediate Excel), reporting tools, and case management/audit systems.
- Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems, grouper tools, and audit platforms.
- Self-starter with the ability to work independently in a remote setting with minimal supervision.
- Willingness and ability to lead, communicate ideas, take initiative, and drive the team to achieve organizational goals.
- One of the following active certifications: RHIA, RHIT, CCS, CPC, COC
- experience in a hospital or health system setting, with demonstrated expertise in APC grouping and OPPS payment rules.
- experience in a provider, payer, or audit vendor environment.
- experience in a similar business environment (preferably
- experience overseeing remote coding audit staff). •
- Experience reviewing outpatient facility claims for coding accuracy and applying APG reimbursement guidelines during audit and overpayment identification activities.
- Multiple coding credentials and/or advanced healthcare reimbursement certifications.
- Advanced knowledge of APG reimbursement methodologies, including payment logic, grouping principles, reimbursement calculations, and their application to audit and overpayment identification. •
- Experience with payer edit development, outpatient OPPS reimbursement policy, or clinical edit logic related to outpatient facility claims. •
- Experience utilizing operational metrics, dashboards, and reporting tools to manage productivity, quality, and audit outcomes.
- Familiarity with outpatient prospective payment auditing for Medicare Advantage, Medicaid Managed Care, or Commercial payer programs. •
- Experience with grouper software (e.g., 3M APC Grouper, Optum APG Grouper) and audit management platforms.
- Knowledge of the IPPS/OPPS distinction as it relates to hospital billing compliance and audit scope definitions.
- You will have a strong understanding of the role.
- You have mastered the tasks and
Experience
- 7+ years of facility outpatient coding
- 2+ years of outpatient facility coding audit, performing pre-payment and post-payment reimbursement reviews, or payment integrity
- 3+ years of relevant management or leadership
Benefits
- 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.
- 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
- benefits including life insurance, short-term disability, and parental leave.
Additional details
- 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.
- The Supervisor, Outpatient Audit Operations leverages deep expertise in outpatient facility and professional coding, Ambulatory Payment Classification (APC) grouping, Ambulatory Patient Group (APG) methodology, and the Outpatient Prospective Payment System (OPPS) to lead a remote team of outpatient coding auditors conducting pre-payment and post-payment reimbursement-based audits to identify overpayment opportunities and deliver accurate, defensible audit outcomes.
- This role combines hands-on outpatient coding and reimbursement expertise with strong leadership skills to support operational excellence through capacity planning, workforce management, productivity oversight, and strategic resource allocation.
- The Supervisor partners with management to assess business needs, optimize team performance, and ensure audit operations align with client expectations, regulatory requirements, and organizational objectives.
- Oversees and reviews audit determinations to ensure consistency in APC/APG grouping decisions, OPPS packaging interpretation, and outpatient coding policy application.
- Effectively contributes to the development of medical review guidelines, coding education materials, and outpatient-specific training content.
- Supports audit management and subject matter experts with new concept implementation and ongoing maintenance of outpatient medical review guidelines, including annual OPPS updates and CMS rule changes.
- Accountable for achieving established productivity, quality, turnaround time, and employee engagement goals for the assigned team.
- Ensures audit activities are performed in accordance with applicable regulatory requirements, client contracts, organizational policies, and industry standards.
- Identifies process inefficiencies and implements solutions to improve accuracy, consistency, and productivity.