The future of payment integrity.
Medical Review Nurse – CMS/RAC Auditor, Government Audits
Location
United States
Posted
2 days ago
Salary
0
Seniority
Senior
Job Description
Medical Review Nurse – CMS/RAC Auditor, Government Audits
Machinify
• Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. • Document all findings referencing the appropriate policies and rules. • Generate letters articulating audit findings. • Supporting your findings during the appeals process if requested. • Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. • Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. • Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members. • Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. • Interface with and support the Medical Director and cross train in all clinical departments/areas. • Other duties as required to meet business needs.
Job Requirements
- Active unrestricted RN license in good standing, is required.
- Must not be currently sanctioned or excluded from the Medicare program by the OIG.
- 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, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
- Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
- RAC certification preferred.
Benefits
- Equal Employment Opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status.
- Participation in E-Verify as required by applicable law.
- Commitment to reasonable accommodation during the application or recruitment process.
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