[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.

Responsibilities

• Oversees and reviews audit determinations to ensure consistency in APC/APG grouping decisions, OPPS packaging interpretation, and outpatient coding policy application
• Uses data, reports, and experience to proactively identify potential backlogs and align resources to meet business needs and SLAs
• Effectively contributes to the development of medical review guidelines, coding education materials, and outpatient-specific training content
• Supports 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 changes
• Accountable for achieving established productivity, quality, turnaround time, and employee engagement goals for the assigned team
• Ensures audit activities are performed in accordance with applicable regulatory requirements, client contracts, organizational policies, and industry standards
• Identifies process inefficiencies and implements solutions to improve accuracy, consistency, and productivity
• Monitors audit quality performance and collaborates with Quality Assurance and leadership teams to ensure consistency, accuracy, and defensibility of audit findings
• Supervises daily activities of outpatient coding audit staff members, ensuring adherence to productivity, quality, and compliance standards
• Provides coding, audit, and compliance guidance to audit review staff; serves as an escalation resource for complex outpatient coding, reimbursement, and audit-related issues
• Ensures 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) logic
• Routinely provides production and quality performance-based progress reports, coaching, and constructive feedback to staff
• Manages team Time and Attendance (time off/use of accruals, attendance, and timecards for hourly staff) in accordance with applicable policies and procedures
• Collaborates with HR for applicable corrective action as needed
• Completes and conducts performance reviews for assigned staff
• Conducts regular team meetings with direct reports and escalates to management as appropriate to bring timely solutions to employee matters
• Identifies outpatient coding trends and presents solutions to management
• Supports management with strategy activities including needs assessments, capacity planning, staffing models, cost/benefit analysis, and establishing productivity and quality standards
• Proactively monitors team staffing levels in alignment with applicable management to ensure business segment objectives are met
• Provides support as needed to ensure auditors are equipped with the tools and resources required to perform outpatient coding audits effectively
• Participates 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 training
• Maintains 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 trends
• May support management with activities to monitor inventory and activity of third-party/subcontractors
• Supports hiring, onboarding, training, retention, and ongoing professional development initiatives to ensure staff competencies and performance
• Fosters a collaborative, accountable, and high-performing team environment
• Performs other incidental and related duties as required and assigned to meet business needs
• Partners with Quality Assurance teams to identify opportunities for improvement and standardization
• Serves as a point of contact for operational and coding-related escalations
• Supports implementation of new clients, workflows, audit programs, and process enhancements
• Collaborates with cross-functional teams to achieve organizational objectives
• Analyzes operational, productivity, and quality metrics; develops reports and dashboards; communicates trends, risks, results, and recommendations to leadership and stakeholders

Skills

• One of the following active certifications: RHIA, RHIT, CCS, CPC, COC
• 7+ years of facility outpatient coding experience in a hospital or health system setting, with demonstrated expertise in APC grouping and OPPS payment rules
• 2+ 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 environment
• 3+ 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 activities
• Demonstrated success managing productivity, quality, turnaround time, and workforce performance metrics in a remote audit environment
• Multiple coding credentials and/or advanced healthcare reimbursement certifications
• Advanced knowledge of APG reimbursement methodologies, including payment logic, grouping principles, reimbursement calculations, and their application to audit and overpayment identification
• Experience with payer edit development, outpatient OPPS reimbursement policy, or clinical edit logic related to outpatient facility claims
• Experience utilizing operational metrics, dashboards, and reporting tools to manage productivity, quality, and audit outcomes
• Familiarity with outpatient prospective payment auditing for Medicare Advantage, Medicaid Managed Care, or Commercial payer programs
• Experience with grouper software (e.g., 3M APC Grouper, Optum APG Grouper) and audit management platforms
• Knowledge of the IPPS/OPPS distinction as it relates to hospital billing compliance and audit scope definitions

Benefits

• 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

Company Overview