Medical Review Nurse - Commercial DME Auditor

The role

The Medical Review Nurse II performs 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 inpatient and outpatient settings.
• Documenting findings referencing appropriate policies and rules.
• Generating letters articulating audit findings.
• Supporting findings during the appeals process if requested.
• Working 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 to minimize the number of appeals.
• Suggesting ideas to improve audit workflows.
• Assisting with QA functions and training team members.

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 years diversified nursing experience providing direct care in an inpatient or outpatient setting
• One or more years experience performing medical records review
• One or more years experience in health care claims demonstrating expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital
• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual
• Deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding
• Knowledge of insurance programs, 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
• Ability to independently use standard office computer technology and experience using a case management system/tools

Nice to have

• Experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions

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.