Medical Review Nurse – CMS/RAC Auditor, Government Audits

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

📋 Description

• Review claims to ensure medical necessity for inpatient and outpatient services in accordance with medical review guidelines, policies, and regulations.

• Record audit results with relevant policy and rule citations.

• Create letters that articulate audit conclusions.

• Provide support for findings during appeal processes when required.

• Work with the audit team to pinpoint vulnerabilities and potential cases of abuse, securing necessary approvals.

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

• Stay informed about changes in medical practices, technologies, and regulatory matters that impact clients.

• Assist in reducing appeals, propose workflow enhancements, contribute to quality assurance, and train team members.

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

• Support and interface with the Medical Director while cross-training across various clinical departments.

• Carry out additional duties as necessitated by business requirements.

⛳️ Requirements

• Proficient in utilization management systems or clinical decision-making tools such as MCG or InterQual.

• Extensive knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.

• Familiarity with insurance program coverage and payment regulations.

• Capacity to produce high-quality work while adhering to strict deadlines.

• Exceptional written and verbal communication abilities.

• Skill in managing multiple responsibilities, including desk audits and claims evaluations.

• Proficient in utilizing standard office technology and case management systems/tools independently.

• Ability to juggle multiple assignments, document findings and recommendations, and effectively organize and prioritize tasks.

• Capability to work autonomously as well as collaboratively in a remote environment.

• An active, 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 years of varied nursing experience delivering direct care in either inpatient or outpatient settings.

• At least one year of experience in medical records review.

• A minimum of one year of experience in healthcare claims, demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an insurance entity or hospital.

• Strong preference for experience in utilization review within an insurance company, Tricare, MAC, or a similar organization.

• RAC certification is preferred; candidates without it may need to pursue certification.

🏝️ Benefits

• Competitive salary and benefits package.

• Opportunities for professional development and training.

• Supportive work environment with a focus on teamwork.

• Flexible working conditions, including remote work options.