SME - Pre/Post Pay Data Mining

Machinify is the leading provider of AI-powered software products that transform healthcare claims and payment operations. Each year, the healthcare industry generates over $200B in claims mispayments, creating incredible waste, friction and frustration for all participants: patients, providers, and especially payers. Machinify’s revolutionary AI-platform has enabled the company to develop and deploy, at light speed, industry-specific products that increase the speed and accuracy of claims processing by orders of magnitude.

Machinify is seeking a SME (Subject Matter Expert)  for pre and /or post pay data mining to lead in the development, prioritization and implementation of new ideation and overall success for pre and post pay data mining on behalf of Machinify’s customers. In addition, the SME will assist in client growth and planning initiatives, product testing, quality enhancements, and related tasks to ensure customer satisfaction.  This role does not have direct reports, but does guide and prioritize the work of others, as well as the work being done on assigned projects.

The ideal person for this role has an extensive background in healthcare claims auditing, claims processing and coding, and a high level of understanding of payment guidelines for CMS, Medicaid and commercial payers. This is an advanced role that requires an individual that understands the industry, has experience leading and growing clients, and has the ability to take initiative to try new ideas, figure things out, and take action in a fast moving and changing environment.  

What you'll do:

• Responsible for client growth.  This includes, but may not be limited to…

  • Monetary goals

  • Production goals

  • Ideation and development goals

  • Prioritization of work and workforce allocation

  • Participating and being an expert in the feedback loop as it pertains to data enhancements, product enhancements, and query enhancements.

• Work directly with management and clients to plan and prioritize growth initiatives

• Collaborate with management, data science, and product development teams to create more comprehensive queries, pricing and software solutions

• Constant development of new auditing concepts by utilizing experience and knowledge of the claims payment cycle, contracts, policies and guidelines

• Conduct comprehensive reviews of pre and post pay claims using any and all available resources, including but not limited to, claims data and client adjudication systems, payment guidelines and compliance with regulatory requirements, contract, pricing systems, medical records, authorizations, etc..

• Serve as a claims billing and payment expert, and resource for the data teams and other departments

• Develop and refine reimbursement policies and procedures in collaboration with the team

• Remain updated with the latest billing guidelines and regulations

• Achieve the expected level of accuracy and quality set by the client for the auditing concept, and for valid claim identification and documentation

• Identifies potential claims outside of the concept where additional recoveries may be available. Develops high-quality, high-value concepts and/or process improvement, tools, etc..

• Meet and/or exceed standard guidelines for production and quality measurements

• **This role does everything from the basic Jr. Auditor role to leading individuals, and must have the ability and desire to take on most any task that promotes the growth of the team, client and company

What you'll bring:

• 10+ years of relative experience

• Subject Matter Expert: The subject is healthcare, and the candidate must be an expert in all (or most) things healthcare, including: data mining (pre and post pay), client engagement experience, researching, developing, document creation, policy creation, healthcare claims pricing, and (but not limited to) healthcare data

• A strong ability to “figure it out” is a MUST.  It isn’t necessary to know or have all of healthcare memorized, but an ability to self teach, research, and find the correct answers or solutions is key to success in this role

• Ability to review payment information against Medicare and payer billing guidelines to make determinations relating to the appropriateness of payments.

• Experience or certification in coding/billing is helpful

• Ability to work in a fast paced environment, shift objectives, and perform multiple tasks at once

• Ability to work independently and as part of a team

  • This includes making decisions based on experience and the best known practices and facts available, as well as collaborating with others to ensure those decisions are in line with the current objectives and priorities being set by management

• Willingness and ability to do whatever is necessary to accomplish workload demands

• Experience meeting hard deadlines, and the delivery of high-quality work is critical

• Strong attention to detail; investigative and deductive reasoning skills are a must

• Must be able to make decisions and conclusions when working with limited information using reference materials and strong problem-solving skills

• Must be proficient in using enterprise productivity and communication tools (e.g., Excel, Word, Gmail, Google Sheets, Slack, etc.); intermediate spreadsheet skills level critical, to include: ability to manipulate a spreadsheet, use formulas, work with pivot tables, run macros within existing spreadsheets; some training provided

• Able to receive constructive feedback and maintain a positive attitude; must be flexible in dealing with change

Preferred skills:

• Prior management experience in a related field

• Experience writing healthcare payment policies

• Experience working with multiple healthcare payers

• Coding certification

What we offer:

• Work from anywhere in the US! Our team is distributed and most of us work from home

• A flexible and trusting environment where you'll feel empowered to do your best work

• Hardworking and supportive colleagues and a leadership team that understands the importance of recruiting and retaining top talent

• Incredible Medical/Dental/Vision benefits for employees & their families.

• Competitive salary and equity, 401(k) sponsorship, life insurance

• Generous Learning and Development Reimbursement policy

The salary for this position is based on an array of factors unique to each candidate: Such as years and depth of experience, set skills, certifications, etc.

Our Recruiting team will let you know if you qualify for a different role/range. Salary is one component of the total compensation package, which includes excellent healthcare, flexible time off, and other benefits and perks.

Equal Employment Opportunity at Machinify

Machinify is committed to hiring talented and qualified individuals with diverse backgrounds for all of its positions. Machinify believes that the gathering and celebration of unique backgrounds, qualities, and cultures enriches the workplace.