Medical Review Nurse - Commercial DME Auditor

New

MachinifyHealthcare claims auditing

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 that demonstrates expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG and medical billing experience.

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 expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an insurance company or hospital.
Have experience with utilization management systems or clinical decision-making tools such as MCG or InterQual.
Have deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
Know insurance program coverage and payment rules.
Be able to maintain work quality while meeting strict deadlines and managing multiple assignments.
Be able to use standard office computer technology and case management systems or tools to review and document findings.
Be able to organize and prioritize workload and work independently and as part of a team in a remote setting.
Utilization review experience with an insurance company, Tricare, MAC, or a similar organization is strongly preferred.
Must not be currently sanctioned or excluded from the Medicare program by the OIG.

Audit claims for medically appropriate services in inpatient and outpatient settings using applicable medical review guidelines, policies, and rules.
Document audit findings with references to the appropriate policies and rules.
Generate letters that articulate audit findings.
Support findings during the appeals process when requested.
Work 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 that may affect clients.
Suggest ways to improve audit workflows, assist with quality assurance, and train team members.
Help establish edit parameters, new issue packets, and Medical Review Guidelines.
Support the Medical Director and cross-train in clinical departments and areas.

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