Medical Review Nurse – Home Health Auditor

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

🔎 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 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 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. • 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. • Cross train in all clinical departments/areas. • Other duties as required to meet business needs.

🎯 Requirements

• An associate or bachelor’s degree in nursing (active/unrestricted RN license) is required. • Medical Coding certification is preferred. • Home Health claims auditing, quality assurance and/or recovery auditing experience of 2 years or more required. • Must have Home Health experience. • Strong focus on quality and attention to detail. • Deep curiosity and analytical skills to understand root causes of events and behaviors. • Proven ability to apply critical judgment in clinical determinations; medical coding ability preferred. • In-depth knowledge of clinical criteria and documentation requirements to support code assignments. • Understanding of ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines is preferred. • Ability to work independently and efficiently in a remote environment.

🏖️ Benefits

• Equal Employment Opportunity at Machinify