Supervisor, Medical Review Audit (Clinical)

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.

The Medical Review Audit Supervisor is a working supervisor who leads a remote team of clinical auditors performing medical record review, with primary oversight of Skilled Nursing Facility (SNF) audits. This role requires a licensed nurse with SNF clinical and/or reimbursement experience, command of Medicare Part A SNF coverage rules, the Patient Driven Payment Model (PDPM), and MDS 3.0 documentation, and the leadership presence to drive performance, hold the team accountable, and develop staff.

Key Responsibilities

Team Leadership & Performance Management

• Directly supervise a team of clinical auditors and audit associates; set clear productivity and quality expectations and hold the team to them consistently.
• Conduct regular performance reviews, coaching conversations, and constructive feedback sessions; escalate performance concerns through appropriate Leader and/or HR channels.
• Lead regular team meetings to align priorities, communicate updates, and maintain engagement in a remote environment.
• Monitor and manage time, attendance, and scheduling in accordance with company policy.
• Identify training gaps and coordinate targeted development, including calibration on PDPM classification, skilled need, and level of care determinations; support onboarding of new audit staff.

SNF Audit Oversight & Quality

• Serve as the primary subject matter authority for SNF audit programs; maintain current, working knowledge of Medicare Benefit Policy Manual Chapter 8 coverage requirements, PDPM, the MDS 3.0 RAI Manual, SNF consolidated billing, and Medicare Advantage and commercial SNF reimbursement policy.
• Maintain personal audit proficiency by performing a limited volume of SNF claim reviews; serve as technical resource and escalation point for complex or disputed cases, including skilled need, level of care, and PDPM component disputes.
• Oversee audit determinations on qualifying hospital stays, physician certification and recertification, daily skilled services, and MDS coding accuracy to ensure findings are consistent, defensible, and grounded in the medical record.
• Collaborate with the QA team to translate audit findings and error trends into clear, actionable feedback for auditors, driving continuous improvement in audit accuracy.
• Monitor team inventory and workflow to proactively identify and address backlogs before they impact SLAs.
• Use production and quality data to identify trends, surface opportunities, and present actionable recommendations to leadership.
• Support implementation of new audit concepts, client requirements, and payer-specific SNF guidelines, including changes from the annual CMS SNF PPS final rule.

Cross-Functional & Strategic Contribution

• Provide reporting and operational updates to management on team activity, performance metrics, and emerging issues.
• Collaborate with QA, Appeals, and segment specialists to resolve operational problems and support continuous improvement.
• Maintain current knowledge of SNF PPS rule changes, MDS item set and RAI Manual updates, and CMS program integrity activity affecting SNF claims.
• Participate in client-facing meetings and support provider training activities.
• Support management in capacity planning, needs assessments, and inventory activity for third-party subcontractors as needed.

Knowledge, Skills, and Abilities

• Deep working knowledge of SNF Part A documentation and coverage requirements, including the 3-day qualifying inpatient stay, physician certification and recertification, daily skilled nursing and therapy needs, and the distinction between skilled and custodial care.
• Command of PDPM case-mix classification, including the PT, OT, SLP, nursing, and NTA components, primary diagnosis clinical category mapping, Section GG functional scoring, and the interrupted stay policy.
• Proficiency in MDS 3.0 coding and RAI Manual guidance, including assessment scheduling, look-back periods, and supporting documentation; ability to validate HIPPS codes against the medical record.
• Strong understanding of CMS, Medicaid, Medicare Advantage, and commercial payer coverage and payment rules for post-acute care, including SNF level of care criteria.
• Proficiency with ICD-10-CM and HCPCS/HIPPS; familiarity with UB-04 institutional claims, SNF bill types, revenue codes, and consolidated billing edits.
• Experience interpreting EHRs, including SNF platforms such as Point Click Care (PCC) or MatrixCare, and applying clinical documentation standards to audit determinations.
• Ability to read, analyze, and clearly communicate complex clinical and billing findings, verbally and in writing, at all organizational levels.
• Strong data analysis skills; able to synthesize production and quality metrics into operational insights.
• Demonstrated track record of leading teams to performance outcomes, not just managing tasks.
• Comfortable operating with ambiguity; identifies problems and drives to resolution without waiting to be directed.
• Proficient in Microsoft Office Suite (intermediate Excel required); experience with case management or audit platforms preferred.

Required Qualifications

• Active, unrestricted nursing license in good standing; not sanctioned or excluded from Medicare by OIG.
• 3+ years of direct patient care experience, including skilled nursing or post-acute care.
• 2+ years performing medical record audits, MDS review, or clinical reimbursement review in a payer, provider, or SNF setting, with direct experience in SNF Part A claims.

• 3+ years of supervisory or team leadership experience in a comparable production environment, or demonstrated readiness for people leadership through activities such as training, mentorship, subject matter expert, or equivalent; experience managing or supporting remote staff strongly preferred

Preferred Qualifications

• Resident Assessment Coordinator Certified (RAC-CT or RAC-CTA) through AAPACN.
• Medical coding certification (CPC, CCS, or equivalent).
• Prior experience as an MDS Coordinator, Director of Nursing, or Director of Clinical Reimbursement in a SNF.
• Experience with Medicare Advantage SNF prior authorization or concurrent review.
• Familiarity with SNF appeals workflows, including MAC redeterminations, and payer-provider dispute resolution processes.
• 5+ years of healthcare claims, coding, or clinical reimbursement experience with demonstrated expertise in ICD-10, PDPM, and MDS coding; SNF billing or MDS coordination experience required.