Medical Review Nurse - Commercial DME Auditor

Machinify

1d•Remote

About The Position

Machinify is a healthcare intelligence company serving health plans across the country with an AI-powered platform and expertise across the payment continuum. The Medical Review Nurse II - Commercial DME primarily conducts medical claims audit reviews, joining experienced medical auditors and coders who perform retrospective and prepayment audits for Government and Commercial Payers. The role works remotely in a fast-paced, dynamic environment as part of a multi-location team.

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 performing medical records review.
At least one year of healthcare claims experience demonstrating expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG, and medical billing for an insurance company or hospital.
Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (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 outlining 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

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 relevant medical review guidelines, policies, and rules.
Document findings with references to the appropriate policies and rules.
Generate letters that explain 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 contractors to improve medical policies, provider education, and system edits.
Stay current on medical practice, technology changes, and regulatory issues that may affect clients.
Help reduce appeals, suggest improvements to audit workflows, and assist with quality assurance and team training.
Participate in establishing edit parameters, preparing new issue packets, and developing Medical Review Guidelines.
Interface with and support the Medical Director, and cross-train in clinical departments and areas.
Perform other duties as required to meet business needs.