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.
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. This role leads the development, maintenance, testing, and optimization of post-acute payment integrity audit concepts and partners with operations, clinical, client services, and technology teams to ensure each concept is built, validated, and maintained in alignment with coding standards, coverage and medical necessity criteria, documentation requirements, and client-specific payer policy.
The ideal candidate brings authoritative, 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. This role requires strong analytical and communication skills, a track record of leading audit concept development, the ability to manage complex workflows independently, and the ability to mentor a team of subject matter experts.
Essential Duties and Responsibilities
Policy Development and Maintenance
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 existing audit concepts on required periodic cycles or 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 changes to National Coverage Determinations (NCDs), DME MAC Local Coverage Determinations (LCDs) and Policy Articles, the Medicare Benefit Policy and Claims Processing Manuals, and CMS transmittals, and document their impact on existing concepts.
Interpret and apply client-specific commercial and Medicaid payer policy, including home infusion per diem billing, DME rental and purchase rules, and prior authorization requirements.
Approach for Medicaid audit development in DME and Home Health across multiple states and managed care contracts, the audit program should be built around both federal requirements and state-specific contract obligations.
Policy Testing and Validation
Perform QA reviews of audit concepts to confirm compliance with regulatory, coding, and citation changes and to confirm updates are applied timely.
Validate concept logic against post-acute billing rules, including DME capped rental and oxygen payment rules, modifier requirements (e.g., KX, GA, GZ, RR, NU, UE), 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 prior to deployment.
Operational and Workflow Support
Manage, track, and progress multiple tasks across concurrent audit concept workflows with a high degree of accuracy and quality, delivering results on time.
Ensure audit teams apply post-acute policies consistently and correctly across auditing platforms and client programs.
Serve as the escalation point for auditors and clinical reviewers on complex DMEPOS, home health, and…