Medical Review Nurse – CMS/RAC Auditor, Government Audits

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

📋 Description

• Conduct audits of claims to ensure the provision of medically appropriate services in both inpatient and outpatient environments by adhering to relevant medical review guidelines, policies, and regulations.

• Record all findings while referencing the corresponding policies and regulations.

• Create letters that clearly convey audit findings.

• Provide support for your findings during the appeals process when requested.

• Collaborate with the audit team to identify and seek approval for specific vulnerabilities and/or cases that may be subject to potential misuse.

• Partner with our clients, CMD colleagues, and other contractors to enhance medical policies, provider education, and system edits.

• Stay informed about medical practices, technological advancements, and regulatory matters that could impact our clients.

• Collaborate with the team to reduce the number of appeals; propose ideas to enhance audit workflows; assist with QA functions and train team members.

• Engage in setting edit parameters, developing new issue packets, and crafting Medical Review Guidelines.

• Interface with and support the Medical Director while cross-training in all clinical departments/areas.

• Perform other duties as necessary to fulfill business requirements.

⛳️ Requirements

• An active and unrestricted RN license in good standing is mandatory.

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

• A minimum of five (5) years of diverse nursing experience providing direct care in inpatient or outpatient settings.

• At least one (1) year of experience in performing medical records review.

• A minimum of one (1) year of experience in healthcare claims, demonstrating expertise in ICD-9/ICD-10 coding, HCPS/CPT coding, DRG, and medical billing for an insurance company or hospital is required.

• Strong preference for candidates with experience in utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.

• RAC certification is preferred.

🏝️ Benefits

• Equal Employment Opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status.

• Participation in E-Verify as mandated by applicable law.

• Commitment to reasonable accommodation during the application or recruitment process.