Medical Review Nurse – Home Health Auditor

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

📋 Description

• Conduct audits on claims to ensure the medical appropriateness of services rendered in both inpatient and outpatient environments by applying relevant medical review guidelines, policies, and regulations.

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

• Create letters that clearly communicate audit findings.

• Provide support for your findings during the appeals process if necessary.

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

• Partner with our clients, CMD colleagues, and other contractors to enhance medical policies, educate providers, and refine system edits.

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

• Collaborate with the team to reduce the volume of appeals; propose ideas to enhance audit workflows; assist with quality assurance functions and mentor team members.

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

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

⛳️ Requirements

• 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 (5) years of diverse nursing experience providing direct care in a Home Health setting is required.

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

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

• Preference will be given to candidates with experience in performing utilization review for an insurance company, Tricare, MAC, or similar organizations.

🏝️ Benefits

• Medical coverage

• Dental coverage

• Vision coverage

• HSA/FSA options

• Life insurance coverage

• 401(k) savings plans

• Family/parental leave

• Paid holidays

• Annual paid time off