Medical Review Nurse II - SNF/MDS Auditor

The role

The Medical Review Nurse II - SNF/MDS performs Skilled Nursing Facility medical claims audit reviews. You will perform retrospective and prepayment audits on claims for Government and Commercial Payers.

What you will do

• Auditing claims for medically appropriate services in skilled nursing facility settings.
• Documenting findings referencing appropriate policies and rules.
• Generating letters articulating audit findings.
• Supporting audit findings during the appeals process if requested.
• Collaborating with the audit team to identify vulnerabilities or cases subject to potential abuse.
• Partnering with clients and colleagues to improve medical policies, provider education, and system edits.
• Keeping abreast of medical practice, technology changes, and regulatory issues.
• Working with the team to minimize appeals and suggesting workflow improvements.
• Assisting with QA functions and training team members.
• Participating in establishing edit parameters and Medical Review Guidelines.

Required qualifications

• Active unrestricted RN license in good standing
• 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 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
• Comprehension of the Uniform Medical Billing Form (UB-04) and application to the MDS billing process
• Experience with and deep knowledge of ICD-9, ICD-10, HCPCS coding
• Knowledge of PDPM payment Items contributing to payment methodologies
• Ability to maintain high quality work while meeting strict deadlines
• Excellent written and verbal communication skills
• Ability to independently work within Microsoft Office products

Nice to have

• Experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions
• Understanding and in-depth comprehension of PDPM HIPPS codes including HIPPS Clinical Categories and the components that comprise the HIPPS categories
• Knowledge of RUG and LOC commercial payors
• Understanding of Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF

About the company

Machinify is a healthcare intelligence company that delivers value, transparency, and efficiency to health plan clients. It uses an AI-powered platform and expertise to maximize financial outcomes and drive down healthcare costs.