[Hiring] Medical Review Nurse - CMS/RAC Auditor @Machinify

Role Description

The Medical Review Nurse - CMS / RAC (Government Audits) primarily performs medical claims audit reviews for government clients. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government Payers. You will work remotely in a fast-paced and dynamic environment and be part of a multi-location team.

Please note: RAC certification is preferred for this role. The selected candidate may need to work toward RAC certification if they do not currently have it.

Key Responsibilities:

• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies, and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support your findings during the appeals process if requested.
• Work collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Partner with clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect clients.
• Work with the team to minimize the number of appeals; suggest ideas that may improve audit workflows; assist with QA functions and training team members.
• Participate in establishing edit parameters, new issue packets, and development of Medical Review Guidelines.
• Interface with and support the Medical Director and cross-train in all clinical departments/areas.
• Other duties as required to meet business needs.

Qualifications

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
• Knowledge of insurance programs, particularly the 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.
• Must be able to independently use standard office computer technology (e.g., email, telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload.
• Effectively work independently and as a team, in a remote setting.

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 that demonstrates expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG, and medical billing experience for an Insurance Company or hospital required.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• RAC certification preferred.

Company Description

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.