Supervisor, Outpatient Audit Operations

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.

About the Opportunity 

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. 

What you’ll do 

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 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.

What experience you bring (Role Requirements)  

Outpatient Coding & Reimbursement

• Comprehensive knowledge of the CMS Outpatient Prospective Payment System (OPPS) including APC grouping logic, status indicators, packaging rules, composite APCs, and pass-through payments.
• Strong working knowledge of Ambulatory Patient Groups (APG) methodology, including APG weight assignment, significant procedure logic, medical visit consolidation, and ancillary packaging.
• Proficiency in CPT/HCPCS Level II coding for outpatient facility services, including correct modifier application.
• Working knowledge of the National Correct Coding Initiative (NCCI) procedure-to-procedure (PTP) edits and Medically Unlikely Edits (MUEs), and Outpatient Code Editor (OCE) logic.
• Familiarity with Ambulatory Surgical Center (ASC) payment system and APC-based ASC grouping as it relates to outpatient coding audits.
• Knowledge of observation services, two-midnight rule implications, and the relationship between observation status and outpatient OPPS billing.
• Understanding of revenue codes and UB-04 claim form completion requirements for outpatient hospital billing.
• Strong knowledge of ICD-10-CM coding as applied to outpatient encounters, including first-listed diagnosis selection, symptom/sign coding conventions, and POA indicator requirements.
• Familiarity with CMS, Medicaid, and Commercial payer coverage and payment rules for outpatient services, including LCD/NCD applicability.

Leadership & Operations

• Demonstrated ability to successfully develop, lead, and motivate a remote team to high performance; effectively provides constructive feedback and coaching for successful outcomes.
• Experience in developing, documenting, and implementing outpatient coding audit processes and procedures.
• Skill in analyzing information, identifying coding, and billing trends, and presenting actionable solutions to leadership.
• Proven ability to review, analyze, and research outpatient medical billing, documentation, and coding issues.
• Experience with inventory management, resource planning, and report generation in a coding audit environment.
• Reimbursement policy and/or claims software experience; proficiency with encoder tools (e.g., 3M, Optum/Ingenix, or equivalent).
• Familiarity with interpreting electronic medical records (EHR) in the context of outpatient coding and medical necessity review.

General Skills

• Excellent communication skills, both verbal and written; ability to communicate effectively at all levels within the organization and with external clients.
• Strong analytical skills; synthesizes complex or diverse information; uses experience to complement data.
• Leverages critical thinking, questioning, and listening skills to research and resolve complex outpatient coding issues.
• Strong general technical skills including MS Office applications (Intermediate Excel), reporting tools, and case management/audit systems.
• Solid technical aptitude with demonstrated ability to quickly learn and adapt to new systems, grouper tools, and audit platforms.
• Ability to be flexible and thrive in a high-paced environment with changing priorities, including annual OPPS rule updates and mid-year CMS corrections.
• Self-starter with the ability to work independently in a remote setting with minimal supervision.
• Willingness and ability to lead, communicate ideas, take initiative, and drive the team to achieve organizational goals.
• Serves as a positive role model and demonstrates characteristics that align with a collaborative culture of continuous improvement and high-performing teams.
• Limited travel may be required.

Required & Preferred Qualifications

Required

• 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.

Preferred

• 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.

What Success Looks Like… 

After 3 months  

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• You’ve gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year 

• You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities.
• You see opportunities for career progression and personal development.

What’s in it for you            

• 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 

What values we’ll share with you 

• Ask why
• Think big
• Be humble
• Optimize for customer impact
• Deliver results