Medical Review Nurse – CMS/RAC Auditor, Government Audits
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Job Description
Medical Review Nurse auditing inpatient and outpatient claims for government payers. Supporting appeals, policy improvements, and audit workflows at Machinify, an AI-powered healthcare intelligence company.
Responsibilities:
- Audit claims for medically appropriate inpatient and outpatient services using medical review guidelines, policies, and rules
- Document findings with references to applicable policies and rules
- Generate letters articulating audit findings
- Support findings during the appeals process when requested
- Collaborate with the audit team to identify and obtain approval for vulnerabilities and potential abuse cases
- Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits
- Monitor medical practice, technology changes, and regulatory issues affecting clients
- Help minimize appeals, improve audit workflows, assist with QA, and train team members
- Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines
- Interface with and support the Medical Director and cross-train across clinical departments
- Perform other duties as required by business needs
Requirements:
- Active unrestricted RN license in good standing is required
- Must not be currently sanctioned or excluded from the Medicare program by the OIG
- Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting
- One (1) or more years' experience performing medical records review
- One (1) or more years' experience in health care claims demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing experience for an insurance company or hospital
- Experience with utilization management systems or clinical decision-making tools such as MCG or InterQual
- Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding
- Knowledge of insurance programs, particularly coverage and payment rules
- Ability to maintain high-quality work while meeting strict deadlines
- Excellent written and verbal communication skills
- Ability to manage multiple tasks including desk audits and claims review
- Ability to independently use standard office computer technology and case management systems/tools
- Ability to manage multiple assignments, create documentation, and organize and prioritize workload
- Ability to work independently and as part of a team in a remote setting
Benefits:
- Equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status
- Reasonable accommodation during the application or recruitment process
- Employment at will
- E-Verify participation as required by applicable law
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