IBR Policy and Content Development Analyst

The role

This person will develop, enhance, and perform clinical and coding solutions. They will serve as a subject matter expert for payment integrity policies using expertise in healthcare payment, facility billing, coding, and regulatory requirements.

What you will do

• Review and update existing audit concepts on regular cycles or in response to changes.
• Conduct research and analysis to identify the impact of regulatory, coding, or payer policy changes.
• Interpret and apply client-specific payer policy in audit concept reviews and updates.
• Research, interpret, and embed state-specific Medicare/Medicaid provider manuals and regional regulatory mandates into audit concept configurations.
• Evaluate payer policies to identify gaps and propose new audit concepts to clients.
• Ensure audit concepts are formulated across Medicaid, Medicare, and Commercial program lines.
• Align concepts with industry standards including CMS, MUEs, and CPT/HCPCS coding guidelines.
• Develop, validate, and maintain audit concepts targeting coding unbundling in accordance with NCCI edits.
• Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
• Benchmark concept outcomes against industry standards, historical data, and client baselines.

Required qualifications

• 3+ years’ experience performing payment integrity or auditing facility claims.
• Experience translating complex medical regulations and payer guidelines into clinical content and policy documentation.
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
• Knowledge of national coding standards, particularly payment rules.
• Strong organizational and written communication skills.
• In-depth knowledge of diverse facility reimbursement methodologies and commercial/government payment policies.
• Proficient in Windows office systems, including the full Microsoft Suits.
• Demonstrated experience or proficiency in utilizing AI tools and automation platforms to optimize clinical research.
• Proven ability to communicate effectively with all levels of the organization, diverse teams, and clients.
• Ability to prioritize and multitask.
• At least one of the following coding certificates: RHIA, RHIT, CCS, CPC, CPMA or an Active RN/LPN License

Benefits

• Top Medical/Dental/Vision offerings
• FSA/HSA
• Tuition reimbursement
• Competitive salary
• 401(k) with company match
• Additional health and wellness benefits and perks

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. It uses an AI-powered platform to maximize financial outcomes and drive down healthcare costs.