Medical Review Nurse II - SNF/MDS Auditor

Machinify

15d•$90,000 - $105,000•Remote

About The Position

The Medical Review Nurse II - SNF/MDS primarily performs medical claims audit reviews for skilled nursing facility (SNF) services. The nurse joins a team of experienced medical auditors conducting retrospective and prepayment audits for government and commercial payers. This is a remote role in a fast-paced, dynamic environment with a multi-location team. The position is exempt and salaried, with an expected starting annual salary range of $90,000–$105,000. Actual offers depend on individual candidate evaluations. Specific MDS experience is required.

Requirements

Active, unrestricted RN license in good standing.
Must not be currently sanctioned or excluded from the Medicare program by the OIG.
At least five years of diversified nursing experience providing direct care in an inpatient or outpatient setting.
At least one year of experience with the MDS/RAI process.
At least one year of medical records review experience.
At least one year of healthcare claims experience demonstrating expertise in ICD-9/ICD-10 coding guidelines and their relationship to the MDS RAI process.
Comprehension of the Uniform Medical Billing Form (UB-04) and its application to MDS billing.
Experience and deep knowledge of ICD-9, ICD-10, and HCPCS coding.
Knowledge of PDPM payment items that contribute 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 reviews.
Ability to work independently with Microsoft Office products, including Word, Excel, and PowerPoint, and to create and save documents in folders, set up and use spreadsheets, and copy and paste data between documents.
Ability to manage multiple assignments, document findings or suggestions, and organize and prioritize workload.
Ability to work effectively both independently and as part of a team in a remote setting.

Nice To Haves

Experience performing utilization review for an insurance company, Tricare, MAC, or similar organization.
Understanding and in-depth comprehension of PDPM HIPPS codes, including HIPPS clinical categories and their components.
Knowledge of RUG and LOC for commercial payors.
Understanding of the Medicare Benefit Policy Manual and Medicare Claims Processing Manual for SNF.

Responsibilities

Audit claims for medically appropriate services provided in skilled nursing facility settings, applying relevant medical review guidelines, policies, and rules.
Document findings and reference the applicable policies and rules.
Generate letters explaining audit findings.
Support audit findings during the appeals process when requested.
Collaborate with the audit team to identify vulnerabilities or cases potentially subject to abuse and obtain approval for them.
Partner with clients, CMD colleagues, and other contractors to improve medical policies, provider education, and system edits.
Stay informed about medical practice, technology changes, and regulatory issues that may affect clients.
Work with the team to minimize appeals and suggest improvements to audit workflows.
Assist with quality assurance functions 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 in clinical departments or areas.
Perform other duties as required to meet business needs.