Medical Review Nurse II - SNF/MDS Auditor

New

MachinifyHealthcare claims auditing

Remote - USFull-TimeMiddle

Salary90,000 - 105,000 USD per year

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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 with MDS/ RAI process; 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 guidelines and how it relates to the MDS RAI Process.
Required Skills: Microsoft Office

Hold an active, unrestricted RN license in good standing.
Must not be currently sanctioned or excluded from the Medicare program by the OIG.
Have at least five years of diversified direct-care nursing experience in an inpatient or outpatient setting.
Have at least one year of experience with the MDS/RAI process.
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 guidelines and their relationship to the MDS RAI process.
Understand the Uniform Medical Billing Form (UB-04) and its application to the MDS billing process.
Have experience and deep knowledge of ICD-9, ICD-10, and HCPCS coding.
Know PDPM payment items that contribute to payment methodologies.
Work independently with Microsoft Office products, including Word, Excel, and PowerPoint.
Manage multiple assignments, document findings and suggestions, and organize and prioritize workload while meeting strict deadlines.
Preferred: experience performing utilization review for an insurance company, Tricare, MAC, or similar organization.
Preferred: understanding of PDPM HIPPS codes, HIPPS clinical categories, and their components; knowledge of RUG and LOC commercial payors and the Medicare Benefit Payment and Claims Processing manuals for SNF.

Audit claims for medically appropriate services provided in skilled nursing facility 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 audit findings during the appeals process when requested.
Collaborate with the audit team to identify vulnerabilities or 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 workflow improvements, assist with quality assurance and team training, and participate in developing edit parameters, new issue packets, and Medical Review Guidelines.

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