Audit Policy Analyst, Post-Acute Services

Machinify

5h•Remote

About The Position

Machinify is a healthcare intelligence company serving health plans through an AI-powered payment platform and industry expertise. 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. The role leads the development, maintenance, testing, and optimization of post-acute payment integrity audit concepts, working with operations, clinical, client services, and technology teams to ensure concepts align with coding standards, coverage and medical necessity criteria, documentation requirements, and client-specific payer policy. The analyst applies 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. The role also manages complex workflows independently, communicates across internal teams and with clients, analyzes concept performance, and mentors a team of subject matter experts.

Requirements

Bachelor's degree in nursing, health administration, business, or a related field, or equivalent experience.
At least 5 years of progressive experience in DME, home health, and/or home infusion therapy, including direct experience in payment integrity, claims auditing, or provider-side billing and compliance; alternatively, 3+ years of post-acute claims auditing and recovery auditing experience.
Registered Nurse or Certified Coder with a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent).
Depth and breadth of knowledge of post-acute coding systems and payment methodologies, including ICD-10-CM, HCPCS Level II, CPT, HIPPS, the DME fee schedule and Competitive Bidding Program, Home Health PPS under PDGM, and the Medicare home infusion therapy benefit.
Understanding of DME MAC jurisdictions, LCDs, Policy Articles, and supplier documentation requirements, including Standard Written Orders, face-to-face encounters, proof of delivery, continued need, and the DME Required Prior Authorization List.
Understanding of Medicare home health conditions of payment, including homebound status, face-to-face encounter, certification and recertification, plan of care, OASIS assessment, and Notice of Admission.
Broad knowledge of provider billing guidelines, payer reimbursement policies, medical necessity criteria, and claim adjudication standards for post-acute services.
Expertise in clinical documentation requirements and audit concept development for post-acute claim types.
Experience with data utilization 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.
Ability to communicate effectively with all organizational levels, diverse teams, and external clients.
Strong written and verbal communication skills and attention to detail.
Strong critical-thinking and analytical skills.
Ability to independently manage multiple concurrent workflows and deliver results on time in a remote environment.
Proficiency with Windows office systems and the Microsoft Suite, including Excel, Word, Outlook, PowerPoint, SharePoint, and Teams.
Advanced Microsoft Office skills, particularly Excel and PowerPoint.
Familiarity with encoder and grouper applications, including the Home Health PDGM Grouper.
Experience with various software platforms and collaboration with development teams.
Proven success working remotely.

Nice To Haves

Home health coding credential (HCS-D or BCHH-C).
OASIS credential (COS-C).
Infusion nursing credential (CRNI).

Responsibilities

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 audit concepts periodically and 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 NCDs, DME MAC LCDs and Policy Articles, Medicare Benefit Policy and Claims Processing Manuals, and CMS transmittals, documenting their impact on existing concepts.
Interpret and apply client-specific commercial and Medicaid payer policies, including home infusion per diem billing, DME rental and purchase rules, and prior authorization requirements.
Develop Medicaid audit approaches for DME and home health across multiple states and managed care contracts, considering federal requirements and state-specific contract obligations.
Perform QA reviews to confirm audit concepts comply with regulatory, coding, and citation changes and are updated promptly.
Validate audit logic against post-acute billing rules, including DME capped rental and oxygen payment rules, modifiers, home health 30-day period and LUPA logic, and home infusion therapy visit and drug billing.
Identify discrepancies in concept performance and drive resolution with clinical, coding, and operations teams.
Ensure audit concepts are validated against current coding guidelines, payment methodologies, and payer policy before deployment.
Manage and track multiple concurrent audit concept tasks, delivering accurate, high-quality results on time.
Ensure audit teams apply post-acute policies consistently across auditing platforms and client programs.
Serve as an escalation point for auditors and clinical reviewers on complex DMEPOS, home health, and home infusion documentation and coverage questions.
Create training materials, job aids, and reference tools for audit concepts, including documentation checklists for orders, face-to-face encounters, proof of delivery, homebound status, and plans of care.
Maintain accessible documentation of post-acute audit policies and concept updates.
Respond to client inquiries and support client services with presentations, provider disputes, and escalations involving post-acute claims.
Partner with operations, clinical teams, technology, and internal stakeholders to support policy execution and improve concept quality.
Provide expert feedback to improve policy usability, accuracy, and effectiveness.
Monitor concept performance and conduct statistical analysis to support scoring and selection of audit concepts.
Identify trends in DME, home health, and home infusion claim data and recommend actions to optimize audit yield and accuracy.
Identify opportunities to improve audit concept workflows, documentation processes, and policy management practices.
Support enhancements to concept tracking, QA processes, and cross-functional coordination.
Perform additional responsibilities and ad hoc projects as assigned.