[Remote] Supervisor, Outpatient Audit Operations

Note: The job is a remote job and is open to candidates in USA. Machinify is a leading healthcare intelligence company specializing in payment solutions for health plans. The Supervisor, Outpatient Audit Operations will lead a remote team of outpatient coding auditors to conduct audits that ensure compliance with coding standards and optimize reimbursement processes while achieving productivity and quality goals.ResponsibilitiesOversees and reviews audit determinations to ensure consistency in APC/APG grouping decisions, OPPS packaging interpretation, and outpatient coding policy applicationUses data, reports, and experience to proactively identify potential backlogs and align resources to meet business needs and SLAsEffectively contributes to the development of medical review guidelines, coding education materials, and outpatient-specific training contentSupports audit management and subject matter experts with new concept implementation and ongoing maintenance of outpatient medical review guidelines, including annual OPPS updates and CMS rule changesAccountable for achieving established productivity, quality, turnaround time, and employee engagement goals for the assigned teamEnsures audit activities are performed in accordance with applicable regulatory requirements, client contracts, organizational policies, and industry standardsIdentifies process inefficiencies and implements solutions to improve accuracy, consistency, and productivityMonitors audit quality performance and collaborates with Quality Assurance and leadership teams to ensure consistency, accuracy, and defensibility of audit findingsSupervises daily activities of outpatient coding audit staff members, ensuring adherence to productivity, quality, and compliance standardsProvides coding, audit, and compliance guidance to audit review staff; serves as an escalation resource for complex outpatient coding, reimbursement, and audit-related issuesEnsures team is executing accurate application of CPT/HCPCS Level II coding in the outpatient setting, with proficiency in modifier usage, National Correct Coding Initiative (NCCI) edits, and Outpatient Code Editor (OCE) logicRoutinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staffManages team Time and Attendance (time off/use of accruals, attendance, and timecards for hourly staff) in accordance with applicable policies and proceduresCollaborates with HR for applicable corrective action as neededCompletes and conducts performance reviews for assigned staffConducts regular team meetings with direct reports and escalates to management as appropriate to bring timely solutions to employee mattersIdentifies outpatient coding trends and presents solutions to managementSupports management with strategy activities including needs assessments, capacity planning, staffing models, cost/benefit analysis, and establishing productivity and quality standardsProactively monitors team staffing levels in alignment with applicable management to ensure business segment objectives are metProvides support as needed to ensure auditors are equipped with the tools and resources required to perform outpatient coding audits effectivelyParticipates in and contributes to applicable department meetings; may participate in client-facing meetings to research and analyze issues, present findings and recommendations, and/or provide outpatient coding trainingMaintains current knowledge of changes that affect the industry and clients as they pertain to outpatient coding practice, CMS OPPS final rules, APG reimbursement updates, regulatory changes, and business trendsMay support management with activities to monitor inventory and activity of third-party/subcontractorsSupports hiring, onboarding, training, retention, and ongoing professional development initiatives to ensure staff competencies and performanceFosters a collaborative, accountable, and high-performing team environmentPerforms other incidental and related duties as required and assigned to meet business needsPartners with Quality Assurance teams to identify opportunities for improvement and standardizationServes as a point of contact for operational and coding-related escalationsSupports implementation of new clients, workflows, audit programs, and process enhancementsCollaborates with cross-functional teams to achieve organizational objectivesAnalyzes operational, productivity, and quality metrics; develops reports and dashboards; communicates trends, risks, results, and recommendations to leadership and stakeholdersSkillsOne of the following active certifications: RHIA, RHIT, CCS, CPC, COC7+ years of facility outpatient coding experience in a hospital or health system setting, with demonstrated expertise in APC grouping and OPPS payment rules2+ years of outpatient facility coding audit, performing pre-payment and post-payment reimbursement reviews, or payment integrity experience in a provider, payer, or audit vendor environment3+ years of relevant management or leadership experience in a similar business environment (preferably experience overseeing remote coding audit staff)Experience reviewing outpatient facility claims for coding accuracy and applying APG reimbursement guidelines during audit and overpayment identification activitiesDemonstrated success managing productivity, quality, turnaround time, and workforce performance metrics in a remote audit environmentMultiple coding credentials and/or advanced healthcare reimbursement certificationsAdvanced knowledge of APG reimbursement methodologies, including payment logic, grouping principles, reimbursement calculations, and their application to audit and overpayment identificationExperience with payer edit development, outpatient OPPS reimbursement policy, or clinical edit logic related to outpatient facility claimsExperience utilizing operational metrics, dashboards, and reporting tools to manage productivity, quality, and audit outcomesFamiliarity with outpatient prospective payment auditing for Medicare Advantage, Medicaid Managed Care, or Commercial payer programsExperience with grouper software (e.g., 3M APC Grouper, Optum APG Grouper) and audit management platformsKnowledge of the IPPS/OPPS distinction as it relates to hospital billing compliance and audit scope definitionsBenefitsPTO, Paid Holidays, and Volunteer DaysEligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accountsTuition ReimbursementEligibility for company-paid benefits including life insurance, short-term disability, and parental leave.Remote and hybrid work optionsCompany OverviewMachinify is a SaaS platform that enables non-technical enterprises to build AI-powered products and processes. It was founded in 2016, and is headquartered in Palo Alto, California, USA, with a workforce of 1001-5000 employees. Its website is http://www.machinify.com.