Machinifyinc
Audit Policy Analyst, Post-Acute Services
Remote - US. Posted 23 days ago
The role
The Audit Policy Analyst, Post-Acute Services serves as a subject matter expert for DME, home health, and home infusion therapy claims. This person will develop, maintain, test, and optimize post-acute payment integrity audit concepts.
What you will do
- Develop new post-acute audit concepts for DME, home health, and home infusion therapy claims.
- Review and update existing audit concepts based on client or regulatory changes.
- Monitor and interpret changes to NCDs, LCDs, Policy Articles, and CMS transmittals.
- Interpret and apply client-specific commercial and Medicaid payer policy.
- Perform QA reviews of audit concepts to confirm compliance.
- Validate concept logic against post-acute billing rules.
- Manage, track, and progress multiple tasks across concurrent audit concept workflows.
- Create training materials, job aids, and reference tools.
- Respond to client inquiries and provide subject matter support.
- Monitor concept performance and provide statistical analysis.
Required qualifications
- 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.
- Knowledge of 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.
- Deep understanding of Medicare home health conditions of payment.
- 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.
- Progressive healthcare data analysis experience.
- Experience developing clinical content, policy documentation, and training resources.
Nice to have
- Home health coding (HCS-D, BCHH-C), OASIS (COS-C), or infusion nursing (CRNI) credential
About the company
Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients using an AI-powered platform.