DME Supervisor

About the role

Machinify is seeking a Medical Review Audit Supervisor - Clinical to join our dynamic team. This position is responsible for managing a remote team of nurses and other audit roles, performing clinical review audits, and supporting management with strategy activities.

Responsibilities

• Regularly performs limited volume of clinical audits to maintain subject matter expertise.
• Performs audit quality assurance reviews to supplement QA team activity as necessary.
• Contributes to the resolution of quality review rebuttals.
• May perform appeals review/activity to supplement Appeals team, based upon business need.
• Actively identifies and recommends opportunities for cost savings and improving outcomes.
• Ensures adherence to medical review guidelines and training requirements of staff.
• Supports audit management and segment specialists with activities for new concept implementation.
• Maintains inventory of assigned business to ensure timelines are met.
• Uses data, reports and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs.
• Oversees and reviews audit determinations to ensure consistency in decision-making.
• Collaborates with other departments to resolve operational problems.
• Proactively monitors and ensures activity required to meet team staffing levels necessary to achieve business objectives.
• Supports auditors with tools and resources required to perform audits.
• Supervises daily activities of clinical audit staff.
• Provides audit guidance to medical review staff; identifies trends and presents solutions.
• Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff.
• Manages team Time and Attendance (time off/use of accruals, attendance, attendance points and timecards for hourly staff, etc.) in accordance with applicable policies and procedures.
• Collaborates with The People Team for applicable corrective action as applicable.
• Completes and conducts performance reviews for assigned staff.
• Conducts team meetings with direct reports on a regular basis.
• Provides leadership to team members, provide solutions, and resolve conflicts.
• Escalates to management and collaborates with HR as applicable to bring appropriate solutions to employee matters.
• Provides reporting and updates to management as required and appropriate for operational and staff activity and results.
• Participates in and contributes to applicable department meetings.
• May participate to client-facing meetings; research and analyze issues; present findings and solutions; and/or provider training.
• May support management with activities to monitor inventory and activity of 3rd party/subcontractors.
• Becomes subject matter expert for assigned business segment(s).
• Maintains current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation and business trends.
• Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.
• Receives feedback and adjusts work priority for self and team as necessary.
• Leads by example and conducts work in accordance with company policies, government regulations and law.
• Performs other incidental and related duties as required and assigned to meet business needs.

Requirements

• Current active unrestricted Nursing license in good standing.
• Not currently sanctioned or excluded from the Medicare program by OIG.
• Medical coding certification is a plus.
• 3+ years diverse nursing experience providing direct care in an inpatient or outpatient setting.
• 2+ years of performing medical record audits in a provider setting, or in a payer setting for a health insurance company.
• 5+ years in health care claims that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital.
• 3+ years relevant supervisory or leadership experience in similar business environment, preferred.
• Experience managing remote staff is a plus.
• Some Supervisory experience may be required for certain Supervisor roles.
• Prior experience in payer edit development, and/or reimbursement policy experience a plus.

Qualifications

• Strong knowledge of medical documentation requirements and an understanding of CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.
• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.
• Proficiency with MCS 1500/UB 04 forms.
• Working knowledge of encoder.
• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.
• Proven ability to review, analyze, and research medical billing, documentation, and coding issues.
• Reimbursement policy and/or claims software analyst experience.
• Familiarity with interpreting electronic medical records (EHR).

Skills and Abilities

• Strong knowledge of medical documentation requirements and an understanding of CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules.
• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding.
• Proficiency with MCS 1500/UB 04 forms.
• Working knowledge of encoder.
• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines, Milliman or InterQual.
• Proven ability to review, analyze, and research medical billing, documentation, and coding issues.
• Reimbursement policy and/or claims software analyst experience.
• Familiarity with interpreting electronic medical records (EHR).
• Willing and able to lead by example, communicate ideas, take initiative and drive the team to achieve organizational goals.
• Experience in developing, documenting and implementing process and procedures.
• Experience in inventory management, resource planning and report generation.
• Skilled in analyzing information, identifying trends and presenting solutions.
• Understands inventory management objectives, activities, and key drivers in achieving operational goals.
• Demonstrated ability to consistently apply sound judgment and good effective decision making.
• Excellent communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internally and externally.
• Skilled in collaborating effectively in a variety of settings and topics.
• Excellent editing and proofreading skills.
• Demonstrated ability to successfully develop, lead, and motivate a team to high performance; effectively provides constructive feedback and coaching for successful outcomes.
• Ability to independently organize, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.
• Excellent time management and delivers results balancing multiple priorities.
• Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.
• Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.
• Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.
• Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.
• Ability to create documentation outlining findings and/or documenting suggestions.
• Strong general technical skills, including, but not limited to Desktop and MS Office applications (Intermediate Excel Skills), application reporting tools, and case management system/tools to review and document findings.
• Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.
• Ability to be flexible and thrive in a high pace environment with changing priorities.
• Adaptable to applying skills to diverse operational activities to support business needs.
• Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.
• Serves as positive role model, and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.

Benefits

Equal Employment Opportunity at Machinify We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/