[Hiring] Medical Review Nurse, Clinical Appeals Auditor @Machinify

Role Description

The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditees, disputing findings from medical review audit work, and supporting the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools. The Appeals Auditor is also responsible for:

• Consistently achieving or exceeding productivity goals and quality standards.
• Serving as a subject matter expert and providing supplemental escalation support.
• Performing special project activity as needed.

Key Responsibilities

• Perform clinical reviews on medical records to maintain subject matter expertise.
• Conduct Appeals reviews on medical review audit work completed by the medical review clinical and documentation audit team members.
• Document Appeals results in accordance with department quality policies and procedures.
• Review audit documentation and conduct research to determine audit result accuracy.
• Provide corrections to narrative rationale to correspond with audit determination.
• Contribute to the continuous improvement feedback process.
• Support findings during the appeals process, if needed.
• Monitor, track, and report on all work conducted in accordance with Appeals process.
• Prepare reports for management that includes a variety of data and trends.
• Consult with internal resources as necessary.
• Maintain current knowledge of industry changes affecting medical practice, technology, and regulations.
• Participate in applicable department meetings.
• Complete required training, including information security and compliance training.
• Contribute to continuous improvement of activities.
• Support training material/tools and best practices development.
• Identify opportunities for improvement of audit results.
• Contribute to a positive team environment that fosters open communication.
• Adjust work priority based on feedback.
• Conduct work in accordance with company policies and government regulations.
• Perform other incidental and related duties as required.

Qualifications

• Demonstrated ability to perform claim payment audits with high quality and production results.
• Ability to manage multiple assignments effectively and organize workload.
• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary.
• Strong knowledge of medical documentation requirements and understanding of CMS, Medicaid, and/or Commercial insurance programs.
• Experience with utilization management systems or clinical decision-making tools.
• Working knowledge of encoder may be necessary.
• Familiarity with interpreting electronic medical records (EHR).
• Basic understanding of accounting principles for accounts payable and receivable.
• Strong communication skills, both verbal and written.
• Excellent editing and proofreading skills.
• Strong analytical skills and ability to identify meaningful trends.
• Ability to create documentation outlining findings and/or suggestions.
• Strong general computer skills, including MS Office applications.
• Ability to work independently in a remote setting with minimum supervision.

Requirements

• Active unrestricted RN license in good standing.
• At least 5+ years relevant SNF/MDS experience in a provider or payer environment.
• Not currently sanctioned or excluded from the Medicare program by OIG.
• Strong technical aptitude and intermediate to advanced skills using Excel.
• One or more years of experience in health care claims.
• Strong preference for experience performing utilization review for an insurance company.
• Prior experience in primary audit, utilization management, or review of audit work performed by others.
• Prior experience in payer edit development and/or reimbursement policy a plus.
• Prior experience working in a remote setting is strongly preferred.

Benefits

• Equal Employment Opportunity at Machinify.
• Commitment to 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.
• Participation in E-Verify as required by applicable law.