Medical Review Nurse, Clinical Appeals Auditor

Machinify
United States
Workplace: RemoteFull timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 5+ yearsSkills: ["Documentation","Quality assurance","Analysis","Judgment","Communication"]

Conduct clinical appeals reviews of new evidence, disputing or upholding medical review audit findings and accurately documenting results in line with quality policies. Analyze claims data and audit documentation using client guidelines, coverage/payment rules, and regulations, and route outcomes in the audit platform. Support quality improvement through feedback on documentation and guideline materials, serve as a subject matter expert, and provide escalation and reporting to management.

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Machinify
Machinify
1 day ago

Medical Review Nurse, Clinical Appeals Auditor

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Source: Company careers pageValidated by: Fursa AI
Last checked: 13 hours agoStatus: Live

Job Summary

Conduct clinical appeals reviews of new evidence, disputing or upholding medical review audit findings and accurately documenting results in line with quality policies. Analyze claims data and audit documentation using client guidelines, coverage/payment rules, and regulations, and route outcomes in the audit platform. Support quality improvement through feedback on documentation and guideline materials, serve as a subject matter expert, and provide escalation and reporting to management.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Perform clinical reviews on medical records to maintain subject matter expertise.
  • •Conduct appeals reviews of medical review audit work as new evidence is presented and document, score, and route results according to quality policies.
  • •Review audit documentation and analyze claims data using client SOW, concept guidelines, and applicable regulations to determine accuracy and completeness.
  • •Provide corrections to narrative rationale to match audit determinations and flag patterns of concern to audit leadership for intervention.
  • •Support continuous improvement by suggesting edits to documentation, enhancements to review guidelines/reporting, and participating in training support as needed.

Key Requirements

  • •Active unrestricted RN license in good standing with diversified nursing experience providing direct care in an inpatient or outpatient setting.
  • •At least 5+ years of relevant SNF/MDS experience in a provider or payer environment, demonstrating auditing knowledge/skills; less than 5 years may be considered for internal candidates.
  • •Strong technical aptitude with intermediate to advanced Excel skills.
  • •Experience in health care claims demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, bundled payment methodologies and/or medical billing for an insurance company, hospital, or other provider.
  • •Must not be currently sanctioned or excluded from the Medicare program by OIG.
Experience:5+ yearsHealthcareMedical billingHealth plansPayer
Skills:DocumentationQuality assuranceAnalysisJudgmentCommunication
Licenses:RN license
Languages:English
Tech Stack:ExcelMS OfficeCPTHCPCSICD-9ICD-10EHRCMSMedicaidUtilization management systemsMillimen Care Guidelines (MCG)InterQualEncoderCase management

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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