Medical Review Nurse, Clinical Appeals Auditor

🔥 16 hours ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

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👻 Ghost score 10%

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

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

Healthcare • Consulting • Logistics

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

• Conduct Appeals reviews of new evidence presented by auditees and evaluate disputed medical review audit findings • Perform clinical reviews of medical records to maintain subject matter expertise • Document Appeals results, score and report findings, and route results in the audit platform • Review audit documentation, research claims data, and apply client statements of work, guidelines, policies, and regulations • Correct narrative rationale and flag patterns of concern to audit leadership • Contribute to continuous improvement of documentation, review guidelines, reporting, training materials, tools, and best practices • Support findings during the appeals process and perform primary audit activity as assigned • Monitor, track, and report Appeals work and prepare management reports on data and trends • Serve as a subject matter expert for assigned business segments • Maintain current knowledge of medical practice, technology, regulations, legislation, and business trends • Participate in department meetings and required compliance training • Support training for new or existing audit staff • Collaborate with internal resources and contribute to a positive, high-performing team environment • Perform other related duties as assigned

🎯 Requirements

• Active unrestricted RN license in good standing • Diversified nursing experience providing direct care in an inpatient or outpatient setting • At least 5+ years relevant SNF/MDS experience in a provider or payer environment • Not currently sanctioned or excluded from the Medicare program by OIG • Strong technical aptitude and intermediate to advanced Excel skills • One or more years of experience in health care claims, including ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience, may be required • Experience with utilization management systems or clinical decision-making tools such as Milliman Care Guidelines (MCG) or InterQual • Experience performing primary audits, utilization management, prior authorization work, or reviewing audit work performed by others • Knowledge of medical documentation requirements and CMS, Medicaid and/or Commercial insurance programs may be necessary • Familiarity with interpreting electronic medical records (EHR) • Working knowledge of encoder may be necessary • Reimbursement policy and/or claims software analyst experience may be necessary • Basic understanding of accounting principles for medical billing • Strong analytical, critical-thinking, questioning, listening, communication, editing, proofreading, organization, prioritization, and time-management skills • Ability to run reports, analyze information, identify trends and solutions, create documentation, and resolve complex issues • Strong general computer skills, including desktop and MS Office applications, application reporting tools, and case management systems • Ability to learn and adapt to new systems and tools • Ability to work independently in a remote setting with minimal supervision • Ability to work in a fast-paced, changing environment • Prior remote-work experience is strongly preferred • Experience in payer edit development and/or reimbursement policy is a plus

🏖️ Benefits

• Employment at will • Equal employment opportunity workplace • Reasonable accommodation available during the application or recruitment process