Medical Review Nurse - Home Health Auditor

Machinify
United States
Workplace: RemoteFull timeFunction: Healthcare (Clinical, Medical, Wellness)Experience: 2+ yearsEducation: bachelorsSkills: ["Attention to detail","Analytical skills","Critical judgment","Written communication","Verbal communication"]

Perform retrospective and prepayment medical claims audits for Home Health in a remote, multi-location environment. Review claims for medical appropriateness using established utilization management guidelines and policies, document findings with referenced rules, and generate audit letters. Support audits during appeals when requested, stay current on clinical practice and regulatory changes, and collaborate with the audit team to improve workflows, QA, and training while cross-training across clinical areas.

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FursaFursa
Machinify
Machinify
1 month ago

Medical Review Nurse - Home Health Auditor

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Source: Company careers pageValidated by: Fursa AI
Last checked: 3 hours agoStatus: Live

Job Summary

Perform retrospective and prepayment medical claims audits for Home Health in a remote, multi-location environment. Review claims for medical appropriateness using established utilization management guidelines and policies, document findings with referenced rules, and generate audit letters. Support audits during appeals when requested, stay current on clinical practice and regulatory changes, and collaborate with the audit team to improve workflows, QA, and training while cross-training across clinical areas.
Location: United States
Workplace: Remote
Employment Type: Full time
Job Function: Healthcare (Clinical, Medical, Wellness)
Seniority: Mid level

Key Responsibilities

  • •Audit claims for medically appropriate services in inpatient settings using medical review guidelines, policies, and rules.
  • •Document audit findings with references to the appropriate policies and rules.
  • •Generate letters that articulate audit findings.
  • •Support audit findings during appeals when requested.
  • •Collaborate with the audit team to identify and obtain approval for vulnerabilities/cases subject to potential abuse, and assist with QA and training.

Key Requirements

  • •2+ years of home health claims auditing, quality assurance and/or recovery auditing experience (3+ preferred).
  • •Associate or bachelor’s degree in nursing with an active/unrestricted RN license.
  • •Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
  • •Experience using utilization management systems or clinical decision-making tools such as MCG or InterQual.
  • •Strong written/verbal communication skills and ability to independently manage desk audits and claims reviews while meeting strict deadlines.
Experience:2+ yearsHealthcareHome healthMedical codingClaims auditingUtilization management
Education:Bachelor's in Nursing
Skills:Attention to detailAnalytical skillsCritical judgmentWritten communicationVerbal communication
Licenses:RN
Certifications:CCDSCDIPCCSCIC
Languages:English
Tech Stack:ICD-9ICD-10CPT-4HCPCSMCGInterQualSharePointSlackOutlook CalendarEHR

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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