Audit Policy Analyst, Post-Acute Services

The posting, as Machinify wrote it

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.

As part of the Complex Payment Solutions (CPS) Team, the Audit Policy Analyst, Post-Acute Services serves as the subject matter expert for durable medical equipment (DME), home health, and home infusion therapy claims across government and commercial lines of business. This role leads the development, maintenance, testing, and optimization of post-acute payment integrity audit concepts and partners with operations, clinical, client services, and technology teams to ensure each concept is built, validated, and maintained in alignment with coding standards, coverage and medical necessity criteria, documentation requirements, and client-specific payer policy.

The ideal candidate brings authoritative, hands-on knowledge of how post-acute services are ordered, documented, billed, and paid, including DME MAC policy, the Home Health Patient-Driven Groupings Model (PDGM), and the Medicare home infusion therapy benefit. This role requires strong analytical and communication skills, a track record of leading audit concept development, the ability to manage complex workflows independently, and the ability to mentor a team of subject matter experts.

Essential Duties and Responsibilities

Policy Development and Maintenance

• Develop new post-acute audit concepts for DME, home health, and home infusion therapy claims, including research, data and claim analysis, rule documents, and code lists.
• Review and update existing audit concepts on required periodic cycles or in response to client or regulatory changes, including quarterly HCPCS updates, DMEPOS fee schedule updates, and annual Home Health PPS final rules.
• Monitor and interpret changes to National Coverage Determinations (NCDs), DME MAC Local Coverage Determinations (LCDs) and Policy Articles, the Medicare Benefit Policy and Claims Processing Manuals, and CMS transmittals, and document their impact on existing concepts.
• Interpret and apply client-specific commercial and Medicaid payer policy, including home infusion per diem billing, DME rental and purchase rules, and prior authorization requirements.
• Approach for Medicaid audit development in DME and Home Health across multiple states and managed care contracts, the audit program should be built around both federal requirements and state-specific contract obligations.

Policy Testing and Validation

• Perform QA reviews of audit concept

[…]
lization and statistical analysis, including driving scoring and selection for audit concepts.

• Progressive healthcare data analysis experience, including gathering and documenting requirements for projects of diverse scope and complexity.
• Experience developing clinical content, policy documentation, and training resources.
• Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with external clients.
• Exceptional written and verbal communication skills with strong attention to detail.
• Excellent critical thinking and analytical skills.
• Demonstrated ability to manage multiple concurrent workflows independently and in a remote environment, delivering results on time.

Computer Equipment and Software

• Proficient in Windows office systems, including the full Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
• Advanced skills in Microsoft Office, particularly Excel and PowerPoint.
• Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper.
• Experience working with various software platforms and collaborating with development teams.
• Proven success in a remote working environment.

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/