Medical Review Nurse – CMS/RAC Auditor, Government Audits

🕒 August 11

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 14%

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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

• Audit claims for medically appropriate inpatient and outpatient services while applying medical review guidelines, policies, and rules • Document audit findings with appropriate policy and rule references • Generate letters explaining audit findings • Support findings during appeals when requested • Collaborate with the audit team to identify vulnerabilities and potential abuse cases and obtain approval • Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits • Monitor medical practice, technology changes, and regulatory issues affecting clients • Help minimize appeals, suggest workflow improvements, assist with QA, and train team members • Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines • Interface with and support the Medical Director and cross-train across clinical departments • Perform other duties required by business needs

🎯 Requirements

• Experience with utilization management systems or clinical decision-making tools such as MCG or InterQual • Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding • Knowledge of insurance program 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 case management systems/tools • Ability to manage multiple assignments, document findings and suggestions, and organize and prioritize workload • Ability to work independently and as part of a team in a remote setting • Active unrestricted RN license in good standing required • Must not be currently sanctioned or excluded from the Medicare program by the OIG • Minimum five years of diversified nursing experience providing direct care in an inpatient or outpatient setting • One or more years of medical records review experience • One or more years of healthcare claims experience demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an insurance company or hospital • Strong preference for utilization review experience for an insurance company, Tricare, MAC, or similar organization • RAC certification preferred; candidates without it may need to work toward certification