Supervisor, Outpatient Audit Operations

About the role

The Supervisor, Outpatient Audit Operations leverages deep expertise in outpatient facility and professional coding, Ambulatory Payment Classification (APC) grouping, Ambulatory Patient Group (APG) methodology, and the Outpatient Prospective Payment System (OPPS) to lead a remote team of outpatient coding auditors conducting pre-payment and post-payment reimbursement-based audits to identify overpayment opportunities and deliver accurate, defensible audit outcomes. This role combines hands-on outpatient coding and reimbursement expertise with strong leadership skills to support operational excellence through capacity planning, workforce management, productivity oversight, and strategic resource allocation. The Supervisor partners with management to assess business needs, optimize team performance, and ensure audit operations align with client expectations, regulatory requirements, and organizational objectives.

Responsibilities

• Audit Operations
• 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.
• Team Leadership & Supervision
• 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.
• Operational & Strategic Support
• 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

Benefits

Additional Information

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.

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