Nurse Complex Clinical Claims Analyst

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.

About the Opportunity 

The Complex Clinical Review Analyst is responsible for reviewing facility claims to analyze the  appropriateness of all billed charges compared to a medical record. These reviews will be conducted according to client policy, as well as utilizing industry standards and clinical and coding guidelines to determine the appropriate billing of the services provided. This role requires research and content development for all aspects of claim review, including level of care, experimental and investigation services, HACs, and do not bill events. Resources should be developed and referenced as support for determinations made. This role requires an expert in clinical areas in addition to coding accuracy and payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance. This will be a production based role.

What you’ll do 

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records.
• Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim.
• Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies.
• Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Analyze all medication charges to determine correct pharmacy utilization and potential off-label use.
• Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective.
• Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions.
• Review, expand, and cultivate resources to build up complex claims review content.
• Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims.
• Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters.
• Collaborate and assist in staff training processes and development of training material as needed.
• Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times.
• Assists in special projects and perform other duties as needed.
• Act as a subject matter expert for the overall product.
• Attends all required meetings.

What experience you bring (Role Requirements)  

• Bachelor of Science in Nursing, RN, LPN or LVN
• Equivalent experience of 2+ years in complex claims/ itemized bill review
• Equivalent experience of 3+ years in healthcare billing and coding
• Experience and background in healthcare payment integrity industry
• Exceptional research and data analysis skills
• Possess significant attention to detail and excellent written and verbal skills
• Excellent organizational, analytical, and problem-solving skills
• Capable of handling multiple projects in a fast paced, hyper-growth environment
• Strong ability to work independently and work with internal teams communicating change across the business
• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficient in Windows office systems, including the full Microsoft Suite and Teams
• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various software applications and collaboration with development teams

What Success Looks Like… 

After 3 months  

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• You’ve gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year 

• You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $100,000 - $110,000

This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee’s geographic location. 

What’s in it for you       

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options 

What values we’ll share with you 

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results