DRG Reviewer; Onsite - Hendersonville, TN

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.

Location: This role is onsite in Hendersonville, TN.

The Onsite DRG Reviewer is responsible for providing MS‑DRG and APR‑DRG audit services at provider locations on behalf of our clients. This role requires expertise in healthcare payment methodologies and audit and review criteria to target key claims for review and recovery. The DRG Reviewer examines medical records to validate the accuracy of the UB and items billed for accurate DRG assignment along with appropriate customer payment policies applied to each case reviewed.

The DRG Reviewer must be able to work independently with minimal supervision. Strong customer service skills are required. This position is an onsite audit position that requires the DRG Reviewer to live in the commutable vicinity of Nashville, TN and be able to go onsite daily to the facilities as scheduled.

• Claims Review: Responsible for auditing patient medical records using clinical and coding guideline knowledge along with payer requirements to ensure reimbursement accuracy.
• Written Communication: Provide clear, concise, and compelling rationale and supporting clinical evidence to provider or payer for recommendations or reconsiderations of unsupported billed codes.
• Collaboration: Collaborate with team leaders to ensure DRG denial is thoroughly reviewed.
• Coding Knowledge: Maintains expert knowledge of ICD‑10‑CM/PCS coding conventions and rules, Official Coding Guidelines and American Hospital Association (AHA) Coding Clinic.
• Quality and Time Management: Perform all audits in observance of organizational quality and timeliness standards set by the audit operations management team, meets productivity requirements.
• Technically savvy: Ability to use multiple tools, provider systems, and different medical records systems to perform audits in a comprehensive and timely manner.
• Proficiency: Utilizes proprietary auditing systems and intellectual property with a high level of proficiency to make sound and consistent audit determinations and rationales.
• HIPAA Compliance: Assures HIPAA compliance for protected health information.
• Presentation skills: Participates in exit interviews with the client summarizing audit findings, which can vary depending on client/facility.
• Practice Standards: Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association.
• Other duties as assigned.

• National certification as Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), and/or Certified Coding Specialist (CCS).
• Minimum of five years hospital inpatient coding for IPPS reimbursement and/or at least 2 years’ experience performing DRG validation.
• Previous auditing/ recovery experience preferred.
• Excellent oral and written communication skills.
• Comprehensive knowledge of the DRG structure and regulatory requirements.

• Associate or bachelor’s degree in nursing (active/unrestricted license); or
• Associate or bachelor’s degree in health information management; or
• Work experience may be considered in lieu of formal education at leadership discretion.

• RHIA – Registered Health Information Administrator; or
• RHIT – Registered Health Information Technician; or
• CCDS – Certified Clinical Documentation Specialist; or
• CDIP – Clinical Documentation Improvement Practitioner; or
• CCS – Certified Coding Specialist; or
• CPC‑H, Certified Professional Coder‑H (Hospital Based); or
• CIC, Certified Inpatient Coder.

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