Medical Review Nurse - CMS/RAC Auditor
New
M
MachinifyHealthcare Intelligence
Remote - USFull-TimeMiddle
Salary not disclosed
Apply NowOpens the employer's application page
Job Details
- Experience
- Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.
Requirements
- Active unrestricted RN license in good standing.
- Minimum of 5 years of diversified nursing experience providing direct care in an inpatient or outpatient setting.
- Minimum 1 year of experience performing medical records review.
- Minimum 1 year of experience in health care claims demonstrating expertise in ICD-9/ICD-10, HCPCS/CPT coding, and DRG.
- Experience with medical billing for an insurance company or hospital.
- Proficiency with utilization management systems or clinical decision-making tools (e.g., MCG or InterQual).
- Must not be currently sanctioned or excluded from the Medicare program by the OIG.
- Strong preference for utilization review experience for an insurance company, Tricare, or MAC.
- RAC certification preferred (must be willing to work toward if not currently held).
Responsibilities
- Audit claims for medically appropriate services in inpatient and outpatient settings using medical review guidelines.
- Document all findings referencing appropriate policies and rules.
- Generate letters articulating audit findings.
- Support findings during the appeals process.
- Collaborate with the audit team to identify vulnerabilities and cases subject to potential abuse.
- Partner with clients and colleagues to improve medical policies, provider education, and system edits.
- Participate in establishing edit parameters and development of Medical Review Guidelines.
- Interface with and support the Medical Director.
View Full Description & ApplyYou'll be redirected to the employer's site
