Medical Review Nurse – Commercial DME Auditor

🔥 4 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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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

• Audit claims for medically appropriate services in inpatient and outpatient settings using medical review guidelines, policies, and rules • Document audit findings with references to applicable policies and rules • Generate letters articulating audit findings • Support audit findings during the appeals process when requested • Collaborate with the audit team to identify and obtain approval for vulnerabilities or potential abuse cases • 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, improve audit workflows, assist with QA functions, and train team members • Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines • Interface with and support the Medical Director • Cross-train in clinical departments and areas • Perform 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 demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing experience for an insurance company or hospital • 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 programs, particularly 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 • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or similar organization

🏖️ Benefits

• Remote work arrangement • Equal employment opportunity • Reasonable accommodation during the application or recruitment process • Employment at will