Medical Review Nurse – Clinical Validation

🔥 6 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟢 Junior

🟡 Mid-level

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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

• 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). • CCDS - Certified Clinical Documentation Specialist • CDIP - Clinical Documentation Improvement Practitioner • CCS - Certified Coding Specialist • CIC - Certified Inpatient Coder • Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required. • Inpatient Clinical Documentation Integrity experience of 2 years or more required. • Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. • Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding. • Knowledge of insurance programs program, particularly the coverage and payment rules.

🏖️ Benefits

• Equal Employment Opportunity at Machinify • Committed to 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 • Reasonable accommodation to complete any part of the application or recruitment process • E-Verify participation as required by applicable law