Medical Review Nurse - Home Health Auditor

The role

The Medical Review Nurse II performs medical claims audit reviews with a focus on the Home Health sector. You will perform retrospective and prepayment audits on claims for Government and Commercial Payers.

What you will do

• Auditing claims for medically appropriate services provided for inpatient settings while applying appropriate medical review guidelines, policies and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support findings during the appeals process if requested.
• Work collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Keep abreast of medical practice, changes in technology, and regulatory issues.
• 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.
• Cross train in all clinical departments/areas.

Required qualifications

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g. email SharePoint, slack, outlook calendar etc.).
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload.
• Effectively work independently and as a team, in a remote setting.
• An associate or bachelor’s degree in nursing (active/unrestricted RN license) is required.
• Home Health claims auditing, quality assurance and/or recovery auditing experience of 2 years or more required.
• Must have Home Health experience.

Nice to have

• Medical Coding certification
• CCDS - Certified Clinical Documentation Specialist
• CDIP - Clinical Documentation Improvement Practitioner
• CCS - Certified Coding Specialist
• CIC - Certified Inpatient Coder
• Experience of 3 or more years is preferred.
• medical coding ability preferred
• Understanding of ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines is preferred.

About the company

Machinify is a healthcare intelligence company with expertise across the payment continuum. It delivers value, transparency, and efficiency to health plan clients using an AI-powered platform.