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 medical appropriateness for both inpatient and outpatient services, utilizing established medical review guidelines, policies, and regulations.

• Record findings with citations to relevant policies and regulations.

• Compose letters clearly outlining audit results.

• Provide support for findings during the appeals process as needed.

• Collaborate with the audit team to identify vulnerabilities and potential abuse cases, seeking necessary approvals.

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

• Keep abreast of changes in medical practices, technology, and regulatory matters that impact clients.

• Assist in reducing appeals, optimizing audit workflows, supporting quality assurance, and training team members.

• Engage in the development of edit parameters, creation of new issue packets, and Medical Review Guidelines.

• Interface with and provide support to the Medical Director while cross-training across clinical departments.

• Perform additional duties as required by organizational needs.

⛳️ Requirements

• Must possess an active, unrestricted RN license in good standing.

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

• A minimum of five (5) years of varied nursing experience providing direct care in either an inpatient or outpatient environment is required.

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

• A minimum of one (1) year of experience in health care claims, demonstrating proficiency in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an insurance company or hospital.

• Familiarity with 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.

• Understanding of insurance programs, particularly regarding coverage and payment regulations.

• Capability to maintain high-quality output while adhering to strict deadlines.

• Strong written and verbal communication skills.

• Ability to juggle multiple tasks, including desk audits and claims reviews.

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

• Skilled in managing multiple assignments, generating documentation, and organizing and prioritizing workload.

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

🏝️ Benefits

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

• Reasonable accommodations available during the application or recruitment process.

• Employment is at will.

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