Medical Review Nurse - Home Health Auditor
New
M
MachinifyHealthcare Intelligence
Remote - USFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- 2 years or more
Requirements
- Associate or bachelor’s degree in nursing.
- Active, unrestricted RN license.
- 2+ years of experience in Home Health claims auditing, quality assurance, or recovery auditing.
- Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
- Experience with utilization management systems or clinical decision-making tools (e.g., MCG, InterQual).
- Knowledge of insurance program coverage and payment rules.
- Ability to work independently and efficiently in a remote setting.
- Proficiency in standard office technology (e.g., email, SharePoint, Slack, Outlook).
- Strong attention to detail and analytical skills.
- Medical coding certification (e.g., CCDS, CDIP, CCS, CIC) is preferred.
- 3+ years of Home Health experience is preferred.
Responsibilities
- Audit claims for medically appropriate services in inpatient settings using medical review guidelines and rules.
- Document findings by referencing appropriate policies.
- Generate letters to articulate audit findings.
- Support findings during the appeals process when requested.
- Identify and obtain approval for potential cases of abuse.
- Collaborate with the team to minimize appeals and suggest workflow improvements.
- Assist with QA functions and cross-training team members.
- Stay current on medical practice, technology changes, and regulatory issues.
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