Healthcare Audit Recovery Analyst

ABOUT MACHINIFY:

In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify's AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We're reshaping healthcare payment through seamless intelligence.

ABOUT THE OPPORTUNITY:

The Healthcare Audit Recovery Analyst is responsible for objectively and accurately completing claim audit reviews on assigned Medicare (State) audits while meeting quality and productivity performance goals, as required. This position makes determinations based on claims payment expertise and knowledge while utilizing audit tools and resources available. This role is also responsible for communicating and supporting the identification of additional audit opportunities and participating in development of new ideas, as necessary.

Key Responsibilities to include:

• Conducts Medicaid claim audit reviews and determines if claims are appropriately paid in accordance with benefits, contracts and edits, includes review of specific coding and billing guidelines
• Documents findings within audit tracking system and maintains thorough and objective documentation of findings
• Investigates, researches, and analyzes claims data, applying knowledge of medical or pharmacy policy to determine details of fraudulent or abusive or inaccurate billing activity
• Creates narrative rationale to correspond with audit determinations
• As needed, supports findings during the appeals process
• Serves as a claims payment resource; provides claims payment expertise, and claims payment guidance to the team
• Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse
• Monitors, tracks and reports on all work conducted
• Consults with our clients, physicians, other claims payment resources and contractors as necessary
• Maintains current knowledge of changes in technology, practice and regulatory issues that may affect our clients
• Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives
• As needed, assists with quality assurance functions, development of medical review guidelines and training
• Identifies and recommends opportunities for cost savings and improving outcomes
• Attends conference calls and meetings as requested
• Performs other duties as assigned

Knowledge, Skills & Abilities Needed:

• LTC (Long Term Care) Caseworker or Nursing Home technical and administrative skills preferred
• Understanding of NAMI, Diversion/Deduction Calculations, Spenddown, and Estate Recovery preferred
• Working knowledge of coordination of benefits and medical claims processing
• Knowledge of insurance programs, particularly the coverage and Medicaid payment rules preferred
• Ability to be flexible and seizes the opportunity to cross train
• Ability to maintain high quality work while meeting deadlines and performance metrics
• Excellent organizational, interpersonal and communication skills
• Strong problem solving skills
• Excellent organizational, interpersonal and communication skills
• Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members
• Acute sense of professionalism and confidentiality
• Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel)
• Intermediate level of proficiency with Microsoft Excel, Word and Access
• Experience with EHRs and billing software such as PointClickCare, SigmaCare or MatrixCare
• Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment

Requirements & Qualifications:

• High School Diploma is required. Bachelor's degree, or an equivalent level of competence obtained through experience, education and/or training, may be required for some specific roles
• Medical Coder certification is a plus
• Experience with Commercial healthcare contracts and Reimbursement models (e.g. Medicare, Medicaid, & Commercial Insurance), is required
• 3+ years healthcare claims processing with experience in Medicaid claims
• 3+ years of experience in the health care industry, preferably in an auditing role
• 3+ years working with health care claims demonstrating expertise in, ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or hospital Medical coding experience

WHAT WE OFFER:

Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.

Physical Requirements & Additional Notices:

If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee's responsibility to maintain this Internet access at their home office location.

The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.

• Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.

• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).

• Regularly sit/stand 8 or more hours per day.

• Occasionally lift/carry/push/pull up to 10lbs.

Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:

• Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.

• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.

• Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

• Other requirements may apply.

All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.

Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify's Human Resources team to discuss further.

Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.

THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING