Medical Review Nurse - CMS/RAC Auditor
New
M
MachinifyHealthcare intelligence
Remote - USFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum of five (5) years diversified nursing experience
Requirements
- Active unrestricted RN license in good standing.
- Minimum of 5 years of diversified nursing experience in direct care (inpatient or outpatient).
- Minimum 1 year of experience performing medical records review.
- Minimum 1 year of experience in healthcare claims, including ICD-9/ICD-10, HCPCS/CPT coding, and DRG/medical billing.
- Experience with utilization management or clinical decision-making tools (e.g., MCG or InterQual).
- Proficiency with office computer technology and case management systems.
- Strong ability to manage multiple tasks, meet deadlines, and work independently.
- RAC certification is preferred.
Responsibilities
- Audit claims for medically appropriate services in inpatient and outpatient settings.
- Document findings referencing appropriate policies and rules.
- Generate letters articulating audit findings.
- Support findings during the appeals process as needed.
- Collaborate with the audit team to identify vulnerabilities and potential abuse.
- Improve medical policies, provider education, and system edits in partnership with clients.
- Participate in establishing edit parameters and developing Medical Review Guidelines.
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