The Rawlings Group
Overview
Job Location: Client-Related Site - Nashville, TN. Onsite in Nashville, TN.
Description Who We Are Machinify is a healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. We operate across the payment continuum and serve over 60 health plans, representing more than 160 million lives. We offer a configurable, AI-powered platform with industry expertise to maximize financial outcomes and reduce healthcare costs.
About the Opportunity
The Onsite DRG Reviewer provides MS-DRG and APR-DRG audits at provider locations for our clients. The role requires expertise in healthcare payment methodologies and audit criteria to target key claims for review and recovery. The DRG Reviewer examines medical records to validate the accuracy of billed items for DRG assignment and applied customer payment policies. This is an onsite position in the Nashville, TN area with daily on-site requirements and independent work capability.
What You’ll Do
Claims Review:
Audit patient medical records using clinical and coding knowledge, guidelines, and payer requirements to ensure reimbursement accuracy.
Written Communication:
Provide clear rationale and supporting clinical evidence for recommendations or reconsiderations of billed codes.
Collaboration:
Work with team leaders to ensure thorough review of DRG denials.
Coding Knowledge:
Maintain expert knowledge of ICD-10-CM/PCS coding conventions, Official Coding Guidelines, and AHA Coding Clinic.
Quality and Time Management:
Perform audits in line with quality and timeliness standards; meet productivity requirements.
Technically Savvy:
Use multiple tools and systems to perform audits timely and comprehensively.
Proficiency:
Use proprietary auditing systems to make sound audit determinations.
HIPAA Compliance:
Ensure privacy and security of protected health information.
Presentation Skills:
Participate in client exit interviews to summarize audit findings.
Practice Standards:
Abide by the Standards of Ethical Coding (AHIMA).
Other duties as assigned.
Qualifications General
National certification as RHIA, RHIT, and/or CCS.
Minimum five years hospital inpatient coding for IPPS or at least 2 years' DRG validation experience.
Previous auditing/recovery experience preferred.
Excellent oral and written communication skills.
Comprehensive knowledge of DRG structure and regulatory requirements.
Education (required)
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
Certification (at least one of the following)
RHIA, RHIT, CCDS, CDIP, CCS, CPC-H/Hospital Based, CIC, or equivalent
Experience
Inpatient claims auditing, quality assurance or recovery auditing experience of 2+ years
Inpatient Clinical Documentation Integrity experience of 2+ years
Strong attention to quality, root-cause analysis, and audit judgment
Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA Coding Clinic
Ability to work with minimal supervision
Computer Equipment and Software
Experience with laptops, multiple monitors, remote work, and Windows Office
Familiarity with encoder/grouper tools (e.g., TruCode, 3M) and auditing software
Physical Demands
Ability to sit/stand for long periods; occasional lifting up to 25 pounds; normal vision/hearing
Ability to travel to multiple locations within commuting distance
Pay Range and Status Pay range:
$90,000–$110,000
Employment type:
This is an exempt position. Salary may vary based on experience and location.
Benefits and Perks
PTO, paid holidays, and volunteer days
Health, vision, and dental coverage; 401(k) with company match; flexible spending accounts
Tuition reimbursement
Company-paid life insurance, short-term disability, and parental leave
Remote and hybrid work options
Values What values we’ll share with you:
Ask why
Think big
Be humble
Optimize for customer impact
Deliver results
Across Machinify, we value integrity, teamwork, accuracy, and flexibility. We are committed to equal employment opportunity and comply with applicable laws. If you require a reasonable accommodation during the application process, contact our People Operations team.
EEO Notice Machinify is an equal opportunity employer. We participate in E-Verify as required by law. We do not inquire about salary history in recruitment. See our Candidate Privacy Notice for details.
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Description Who We Are Machinify is a healthcare intelligence company delivering value, transparency, and efficiency to health plan clients. We operate across the payment continuum and serve over 60 health plans, representing more than 160 million lives. We offer a configurable, AI-powered platform with industry expertise to maximize financial outcomes and reduce healthcare costs.
About the Opportunity
The Onsite DRG Reviewer provides MS-DRG and APR-DRG audits at provider locations for our clients. The role requires expertise in healthcare payment methodologies and audit criteria to target key claims for review and recovery. The DRG Reviewer examines medical records to validate the accuracy of billed items for DRG assignment and applied customer payment policies. This is an onsite position in the Nashville, TN area with daily on-site requirements and independent work capability.
What You’ll Do
Claims Review:
Audit patient medical records using clinical and coding knowledge, guidelines, and payer requirements to ensure reimbursement accuracy.
Written Communication:
Provide clear rationale and supporting clinical evidence for recommendations or reconsiderations of billed codes.
Collaboration:
Work with team leaders to ensure thorough review of DRG denials.
Coding Knowledge:
Maintain expert knowledge of ICD-10-CM/PCS coding conventions, Official Coding Guidelines, and AHA Coding Clinic.
Quality and Time Management:
Perform audits in line with quality and timeliness standards; meet productivity requirements.
Technically Savvy:
Use multiple tools and systems to perform audits timely and comprehensively.
Proficiency:
Use proprietary auditing systems to make sound audit determinations.
HIPAA Compliance:
Ensure privacy and security of protected health information.
Presentation Skills:
Participate in client exit interviews to summarize audit findings.
Practice Standards:
Abide by the Standards of Ethical Coding (AHIMA).
Other duties as assigned.
Qualifications General
National certification as RHIA, RHIT, and/or CCS.
Minimum five years hospital inpatient coding for IPPS or at least 2 years' DRG validation experience.
Previous auditing/recovery experience preferred.
Excellent oral and written communication skills.
Comprehensive knowledge of DRG structure and regulatory requirements.
Education (required)
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
Certification (at least one of the following)
RHIA, RHIT, CCDS, CDIP, CCS, CPC-H/Hospital Based, CIC, or equivalent
Experience
Inpatient claims auditing, quality assurance or recovery auditing experience of 2+ years
Inpatient Clinical Documentation Integrity experience of 2+ years
Strong attention to quality, root-cause analysis, and audit judgment
Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA Coding Clinic
Ability to work with minimal supervision
Computer Equipment and Software
Experience with laptops, multiple monitors, remote work, and Windows Office
Familiarity with encoder/grouper tools (e.g., TruCode, 3M) and auditing software
Physical Demands
Ability to sit/stand for long periods; occasional lifting up to 25 pounds; normal vision/hearing
Ability to travel to multiple locations within commuting distance
Pay Range and Status Pay range:
$90,000–$110,000
Employment type:
This is an exempt position. Salary may vary based on experience and location.
Benefits and Perks
PTO, paid holidays, and volunteer days
Health, vision, and dental coverage; 401(k) with company match; flexible spending accounts
Tuition reimbursement
Company-paid life insurance, short-term disability, and parental leave
Remote and hybrid work options
Values What values we’ll share with you:
Ask why
Think big
Be humble
Optimize for customer impact
Deliver results
Across Machinify, we value integrity, teamwork, accuracy, and flexibility. We are committed to equal employment opportunity and comply with applicable laws. If you require a reasonable accommodation during the application process, contact our People Operations team.
EEO Notice Machinify is an equal opportunity employer. We participate in E-Verify as required by law. We do not inquire about salary history in recruitment. See our Candidate Privacy Notice for details.
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