Medical Review Nurse - CMS/RAC Auditor, Government Audits

MachinifyHealthcare auditing

Location: Remote - USFull-TimeSenior

Salary not disclosed

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Job Details

Experience: 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...

Hold an active, unrestricted RN license in good standing.
Have at least five years of diversified nursing experience providing direct care in an inpatient or outpatient setting.
Have at least one year of medical records review experience.
Have at least one year of healthcare claims experience demonstrating ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing experience for an insurance company or hospital.
Have experience with utilization management systems or clinical decision-making tools such as MCG or InterQual.
Demonstrate deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
Know insurance program coverage and payment rules.
Be able to manage multiple assignments, desk audits, and claims reviews while meeting strict deadlines.
Be able to create documentation outlining findings and suggestions and prioritize workload.
Be able to work independently and collaboratively in a remote setting.
RAC certification is preferred; candidates without it may need to work toward certification.
Strong preference for utilization review experience with an insurance company, Tricare, MAC, or similar organization.

Audit claims for medically appropriate services in inpatient and outpatient settings using medical review guidelines, policies, and rules.
Document audit findings with references to applicable policies and rules.
Generate letters explaining audit findings.
Support audit findings during the appeals process when requested.
Collaborate with the audit team to identify vulnerabilities and cases subject to potential abuse and obtain approval for them.
Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits.
Monitor medical practice, technology changes, and regulatory issues affecting clients.
Suggest workflow improvements, assist with QA and team training, and help minimize appeals.
Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines.
Support the Medical Director and cross-train across clinical departments.

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