Medical Review Nurse - CMS/RAC Auditor, Government Audits

Machinify
United States
Workplace: RemoteFull timeFunction: Government & Public AdministrationExperience: 5+ yearsSkills: ["Written communication","Verbal communication","Time management","Independent work","Team collaboration"]

Conduct retrospective and prepayment medical claims audits for government payers, reviewing inpatient and outpatient services against medical review guidelines. Document findings, generate audit letters, and support appeals when requested. Partner with clients and internal teams to improve medical policies, provider education, and system edits, while keeping up with clinical, technology, and regulatory changes. Work remotely with a multi-location audit team to reduce appeals and enhance audit workflows.

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FursaFursa
Machinify
Machinify
1 day ago

Medical Review Nurse - CMS/RAC Auditor, Government Audits

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Canonical indexed version, validated from employer's careers page.

Source: Company careers pageValidated by: Fursa AI
Last checked: 7 hours agoStatus: Live
Reposted: similar role first listed 1 month ago

Job Summary

Conduct retrospective and prepayment medical claims audits for government payers, reviewing inpatient and outpatient services against medical review guidelines. Document findings, generate audit letters, and support appeals when requested. Partner with clients and internal teams to improve medical policies, provider education, and system edits, while keeping up with clinical, technology, and regulatory changes. Work remotely with a multi-location audit team to reduce appeals and enhance audit workflows.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Government & Public Administration
Seniority: Mid level

Key Responsibilities

  • •Audit medically appropriate services for inpatient and outpatient claims using medical review guidelines, policies, and rules
  • •Document findings with references to applicable policies and rules and generate audit letters
  • •Support findings during appeals when requested
  • •Work collaboratively to identify and obtain approval for vulnerabilities/cases subject to potential abuse
  • •Keep current on medical practice, technology, and regulatory issues; help improve audit workflows, QA, training, edit parameters, and medical review guideline development

Key Requirements

  • •Active unrestricted RN license in good standing
  • •Five (5) years of diversified nursing experience providing direct inpatient or outpatient care
  • •One (1)+ year performing medical records review
  • •One (1)+ year in healthcare claims with expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG and medical billing for an insurance company or hospital
  • •Preferred: RAC certification and/or utilization review experience for an insurance company, Tricare, MAC, or similar organizations
Experience:5+ yearsHealthcareInsuranceMedical billingCodingUtilization review
Skills:Written communicationVerbal communicationTime managementIndependent workTeam collaboration
Licenses:RN license
Certifications:RAC
Tech Stack:ICD-9ICD-10CPT-4HCPCSDRGUtilization management systemsMCGInterQualMedicare

Company Brief

Machinify
Provides AI-driven predictive maintenance and asset-monitoring solutions for manufacturing and industrial operations, using IoT sensor data and machine learning to reduce downtime, optimize performance, and extend equipment life.
Industry: Industrial Automation
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