Medical Review Nurse, Clinical Appeals Auditor

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct reviews of Appeals regarding new evidence provided by auditees and assess disputed findings from medical review audits.

• Execute clinical reviews of medical records to uphold subject matter expertise.

• Document the results of Appeals, score and report findings, and route results through the audit platform.

• Examine audit documentation, investigate claims data, and apply client statements of work, guidelines, policies, and regulations.

• Refine narrative rationale and identify patterns of concern to present to audit leadership.

• Contribute to the ongoing enhancement of documentation, review guidelines, reporting, training materials, tools, and best practices.

• Support findings throughout the appeals process and carry out primary audit activities as assigned.

• Monitor, track, and report on Appeals work while preparing management reports on data and trends.

• Act as a subject matter expert for designated business segments.

• Keep up-to-date with current medical practices, technology, regulations, legislation, and industry trends.

• Engage in department meetings and mandatory compliance training.

• Assist in training for new or existing audit personnel.

• Collaborate with internal resources and foster a positive, high-performing team environment.

• Carry out other related responsibilities as assigned.

⛳️ Requirements

• Active unrestricted RN license in good standing.

• Diverse nursing experience providing direct care in either inpatient or outpatient settings.

• A minimum of 5+ years of relevant SNF/MDS experience within a provider or payer environment.

• Must not be currently sanctioned or excluded from the Medicare program by OIG.

• Strong technical skills with intermediate to advanced proficiency in Excel.

• One or more years of experience in health care claims, which may include ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies, and/or medical billing.

• Familiarity with utilization management systems or clinical decision-making tools such as Milliman Care Guidelines (MCG) or InterQual.

• Experience in conducting primary audits, utilization management, prior authorization tasks, or reviewing audit work done by others.

• Knowledge of medical documentation requirements and familiarity with CMS, Medicaid, and/or Commercial insurance programs may be necessary.

• Understanding of how to interpret electronic medical records (EHR).

• Working knowledge of encoders may be beneficial.

• Experience as a reimbursement policy and/or claims software analyst may be advantageous.

• Basic comprehension of accounting principles related to medical billing.

• Strong analytical, critical thinking, questioning, listening, communication, editing, proofreading, organizational, prioritization, and time-management abilities.

• Capability to generate reports, analyze information, identify trends and solutions, create documentation, and address complex issues.

• Proficient general computer skills, including desktop applications and MS Office, application reporting tools, and case management systems.

• Ability to learn and adapt to new systems and tools.

• Capacity to work independently in a remote environment with minimal supervision.

• Ability to thrive in a fast-paced, ever-changing atmosphere.

• Previous remote work experience is highly preferred.

• Experience in payer edit development and/or reimbursement policy is an added advantage.

🏝️ Benefits

• Employment at will.

• Equal employment opportunity workplace.

• Reasonable accommodations available during the application or recruitment process.