Medical Review Nurse II – SNF/MDS Auditor

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $85k - $100k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔎 Auditor

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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 provided in skilled nursing facility settings using applicable medical review guidelines, policies, and rules • Document audit findings with references to relevant policies and rules • Generate letters articulating audit findings • Support audit findings during appeals 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 and suggest audit workflow improvements • Assist with quality assurance functions and train team members • Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines • Support the Medical Director and 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 years of diversified nursing experience providing direct care in an inpatient or outpatient setting • One or more years of experience with the MDS/RAI process • One or more years of experience performing medical records review • One or more years of healthcare claims experience demonstrating expertise in ICD-9/ICD-10 coding guidelines and their relation to the MDS/RAI process • Comprehension of the Uniform Medical Billing Form (UB-04) and its application to the MDS billing process • Experience and deep knowledge of ICD-9, ICD-10, and HCPCS coding • Knowledge of PDPM payment items contributing to payment methodologies • 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 work independently with Microsoft Word, Excel, and PowerPoint, including document and spreadsheet management • Ability to manage multiple assignments, document findings or suggestions, and organize and prioritize workload • Ability to work independently and as part of a team in a remote setting • Preferred: utilization review experience for an insurance company, Tricare, MAC, or similar organization • Preferred: in-depth understanding of PDPM HIPPS codes, clinical categories, and component calculations • Preferred: knowledge of RUG and LOC commercial payors • Understanding of the Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF

🏖️ Benefits

• Remote work • Exempt salaried position • Equal employment opportunity • Reasonable accommodation during the application or recruitment process