Supervisor, Medical Review Audit (Clinical)
New
M
MachinifyHealthcare claims
Location: Remote - USFull-TimeManager
Salary not disclosed
Apply NowOpens the employer's application page
Job Details
- Experience
- 3+ years of direct patient care experience, including skilled nursing or post-acute care; 2+ years performing medical record audits, MDS review, or clinical reimbursement review, with direct experience in SNF Part A claims; 3+ years of supervisory or team leadership experience in a comparable production environment, or demonstrated readiness for people leadership. Preferred: 5+ years of healthcare claims, coding, or clinical reimbursement experience.
- Required Skills
- Microsoft Excel
Requirements
- Maintain an active, unrestricted nursing license in good standing.
- Have 3+ years of direct patient care experience, including skilled nursing or post-acute care.
- Have 2+ years performing medical record audits, MDS review, or clinical reimbursement review, including direct experience with SNF Part A claims.
- Have 3+ years of supervisory or team leadership experience in a comparable production environment, or demonstrated readiness for people leadership through training, mentorship, or subject matter expertise.
- Demonstrate working knowledge of SNF Part A documentation and coverage requirements, including qualifying inpatient stays, physician certification, skilled services, and skilled versus custodial care.
- Demonstrate command of PDPM case-mix classification and its PT, OT, SLP, nursing, and NTA components.
- Be proficient in MDS 3.0 coding and RAI Manual guidance, including assessment scheduling, look-back periods, documentation, and HIPPS code validation.
- Understand CMS, Medicaid, Medicare Advantage, and commercial payer coverage and payment rules for post-acute care.
- Be proficient with ICD-10-CM and HCPCS/HIPPS; familiarity with UB-04 institutional claims, SNF bill types, revenue codes, and consolidated billing edits is required.
- Interpret EHRs, including SNF platforms such as Point Click Care or MatrixCare, and apply clinical documentation standards to audit determinations.
- Use production and quality metrics to identify trends and communicate complex clinical and billing findings clearly.
- Be proficient in Microsoft Office Suite; intermediate Excel skills are required.
Responsibilities
- Supervise clinical auditors and audit associates, setting productivity and quality expectations and addressing performance concerns.
- Conduct performance reviews, coaching conversations, team meetings, and staff development activities.
- Oversee SNF audit determinations, including qualifying hospital stays, physician certifications, daily skilled services, and MDS coding accuracy.
- Perform a limited volume of SNF claim reviews and serve as a technical resource for complex or disputed cases.
- Collaborate with QA to turn audit findings and error trends into actionable feedback for auditors.
- Monitor team inventory and workflow, identifying and addressing backlogs before they affect SLAs.
- Analyze production and quality data and present recommendations and operational updates to leadership.
- Support new audit concepts, client requirements, payer-specific SNF guidelines, and provider training activities.
View Full Description & ApplyYou'll be redirected to the employer's site
