other
Posted 6 days agoQuality Validation Specialist
at Machinify
United StatesHybrid
Responsibilities
- Collaborates with leadership and operational teams to improve audit methodologies, clarify coding guidance, standardize processes, and support continuous quality improvement initiatives.
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.
- 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.
- Maintains current knowledge of outpatient reimbursement methodologies, regulatory updates, coding changes, and industry standards related to Medicare OPPS, APCs, and EAPGs.
- experience you bring (Role Requirements) Required
- Associate’s or Bachelor’s degree in Health Information Management, Healthcare Administration, or a related field preferred.
- Current certification through AHIMA and/or AAPC required, including one or more of the following:
- CCS (Certified Coding Specialist)
- CPC (Certified Professional Coder)
- experience within OPPS reimbursement methodologies and/or at least 5 years of outpatient/APC validation auditing experience.
- Extensive knowledge of CPT, HCPCS Level II, ICD-10-CM, NCCI edits, and appropriate modifier usage.
- Strong understanding of Medicare Outpatient Prospective Payment System (OPPS), Ambulatory Payment Classifications (APCs), and outpatient reimbursement methodologies.
- Experience using industry-standard encoder and auditing tools such as Optum, TrueBridge, and/or 3M.
- Demonstrated ability to review and validate a broad range of outpatient facility services and claim types.
- Excellent verbal and written communication skills with the ability to provide clear, professional feedback and education.
- Ability to work independently and collaboratively in a fast-paced production and quality-driven environment. Preferred
- experience performing pre-pay, post-pay, and/or post-adjudication outpatient validation reviews related to OPPS/APC reimbursement. Advanced