Medical Review Nurse - CMS/RAC Auditor, Government Audits

Machinify

3h•Remote

About The Position

The Medical Review Nurse - CMS/RAC (Government Audits) performs medical claims audit reviews for government clients. The nurse joins a team of experienced medical auditors and coders conducting retrospective and prepayment audits on claims for Government Payers. The role is remote in a fast-paced, dynamic environment and is part of a multi-location team. RAC certification is preferred; a selected candidate who does not currently hold it may need to work toward certification.

Requirements

Active, unrestricted RN license in good standing.
Must not currently be 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 performing medical records review.
At least one year 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.
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 experience using case management systems or tools to review and document findings.
Ability to manage multiple assignments, create documentation of findings or suggestions, and organize and prioritize workload.
Ability to work effectively independently and as part of a team in a remote setting.

Nice To Haves

RAC certification.
Experience performing utilization review for an insurance company, Tricare, MAC, or an organization performing similar functions.

Responsibilities

Audit claims for medically appropriate services in inpatient and outpatient settings, applying applicable medical review guidelines, policies, and rules.
Document findings with references to the applicable policies and rules.
Generate letters that articulate audit findings.
Support findings during the appeals process when requested.
Collaborate with the audit team to identify vulnerabilities or cases subject to potential abuse and obtain approval for them.
Partner with clients, CMD colleagues, and other contractors to improve medical policies, provider education, and system edits.
Stay current on medical practice, technology changes, and regulatory issues that may affect clients.
Work with the team to minimize appeals, suggest audit workflow improvements, and assist with quality assurance and team training.
Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines.
Interface with and support the Medical Director, and cross-train in all clinical departments and areas.
Perform other duties as required to meet business needs.