Medical Review Nurse – Home Health Auditor

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

📋 Description

• Conduct audits on claims for medically appropriate services delivered in both inpatient and outpatient environments, applying relevant medical review guidelines, policies, and regulations.

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

• Compose letters that clearly communicate audit findings.

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

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

• 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 changes that could impact our clients.

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

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

• Interface with and provide support to the Medical Director while 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.

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

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

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

🏝️ Benefits

• Medical

• Dental

• Vision

• HSA/FSA options

• Life insurance coverage

• 401(k) savings plans

• Family/parental leave

• Paid holidays

• Paid time off annually