Medical Review Nurse – CMS/RAC Auditor, Government Audits

🔥 19 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

🤖 Artificial Intelligence

☁️ SaaS

💰 $10M Series A - Machinify on 2018-10

Healthcare Insurance • Artificial Intelligence • SaaS

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• 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.

🎯 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.