<div class="content-intro"><p><span style="color: rgb(0, 0, 0);">Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. 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. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.</span></p></div><div><p style="text-align: left;"><strong><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">About the Opportunity</span></strong></p></div><p><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">The DRG Dispute Reviewer is responsible for evaluating provider appeals and original audit findings to determine the correct DRG assignment and payment outcome. This role requires advanced knowledge of MS-DRG and APR-DRG methodologies, clinical validation, coding guidelines, and payer policies. Using clinical and coding expertise, the reviewer independently assesses documentation to ensure audit decisions are accurate, defensible, and compliant. This position plays a vital role in supporting regulatory compliance, identifying and recovering overpayments, and promoting proper documentation and reimbursement practices across healthcare systems.</span></p><p><strong><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Duties and Responsibilities</span></strong></p><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Dispute Review: Evaluate provider-submitted appeals and original audit findings to validate or revise DRG determinations.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Medical Record Analysis: Review inpatient medical records, UB-04s, and documentation to ensure correct DRG assignment and adherence to coding, billing, and payment guidelines.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">DRG Validation: Apply clinical validation and coding principles to support or overturn DRG audit findings using MS-DRG and APR-DRG grouping logic.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Written Justification: Prepare clear, concise, and evidence-based rationales to support determinations for clients, providers, or payers.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Coding Expertise: Maintain expert knowledge of ICD-10-CM/PCS coding guidelines, UHDDS definitions, and AHA Coding Clinic updates.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Clinical Judgment: Use clinical acumen to assess medical necessity, documentation sufficiency, and code assignment accuracy.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Collaboration: Work closely with audit leads and team members to ensure consistency and quality in dispute resolutions.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Quality & Productivity: Meet performance standards for accuracy, timeliness, and productivity in dispute review and audit completion.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Compliance: Adhere to HIPAA guidelines, industry best practices, and AHIMA’s Standards of Ethical Coding.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Client Communication: Participate in client meetings, including presenting audit results when required.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Tool Utilization: Use proprietary audit platforms, encoders, and medical record systems efficiently and effectively.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Other Duties: Perform additional tasks as assigned to support audit operations and client needs.</span></li></ul><div><strong><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">What You Bring</span></strong></div><div><h3><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Required Education (One of the following):</span></h3><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">An associate or bachelor’s degree in nursing (active/unrestricted license); or in health information management is required.</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Work experience may be considered in lieu of formal education at leadership discretion.</span></li></ul><h3><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Required Certifications (At least one of the following):</span></h3><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">RHIA – Registered Health Information Administrator</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">RHIT – Registered Health Information Technician</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">CCS – Certified Coding Specialist</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">CIC – Certified Inpatient Coder</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">CDIP or CCDS – Clinical Documentation Improvement certification</span></li></ul><h3><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Experience:</span></h3><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Minimum 3 years of inpatient hospital coding (IPPS reimbursement)</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Minimum 4 years DRG validation (clinical and coding)</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Experience in DRG dispute reviews, clinical validation, and recovery audits strongly preferred</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Prior experience in inpatient clinical documentation integrity (CDI) is a plus</span></li></ul><h3><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Skills and Competencies:</span></h3><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Expert-level knowledge of ICD-10-CM/PCS coding systems, MS-DRG/APR-DRG methodologies, and official guidelines</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Strong analytical and critical thinking skills for complex case reviews</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Ability to write clear, professional rationales supported by clinical and coding evidence</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">High attention to detail, accuracy, and compliance</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Able to work independently with minimal supervision in a remote environment</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Technically proficient with:</span><ul><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Medical record systems and audit platforms</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Encoder/grouper tools (e.g., TruCode, 3M)</span></li><li style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);"><span style="font-family: arial, helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">Microsoft Office Suite (Excel, Word, Outlook, Teams)</span></li></ul></li></ul></div><div><strong><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">What We Offer</span></strong></div><ul><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Work from anywhere in the US! Machinify is digital-first.</span></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Top Medical/Dental/Vision offerings</span></div></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">FSA/HSA</span></div></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Tuition reimbursement</span></div></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Competitive salary, 401(k) with company match</span></div></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Additional health and wellness benefits and perks</span></div></li><li style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;"><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Flexible and trusting environment where you’ll feel empowered to do your best work</span></li></ul><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">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. We are hiring for different levels, and our Recruiting team will let you know if you qualify for a different role/range. </span></div><div> </div><div><span style="color: rgb(0, 0, 0); font-family: arial, helvetica, sans-serif; font-size: 12pt;">Pay range: $100,000 - $115,000, with eligibility for quarterly bonuses. </span></div><div> </div><div class="content-conclusion"><div><span style="color: rgb(0, 0, 0);"><strong>Equal Employment Opportunity at Machinify</strong></span></div><div> </div><div><span style="color: rgb(0, 0, 0);">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: <u><a id="m_4907613542122963413OWAae7934b9-fa06-3f98-e336-0c5f8a6d5638" style="color: rgb(0, 0, 0);" href="https://www.machinify.com/candidate-privacy-notice/" target="_blank" data-saferedirecturl="https://www.google.com/url?q=https://www.machinify.com/candidate-privacy-notice/&source=gmail&ust=1763168899816000&usg=AOvVaw0FJrzi47RtxTK_RN63lbaj">https://www.machinify.com/candidate-privacy-notice/</a></u></span></div></div>