Medical Review Nurse – Home Health Auditor

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

📋 Description

• Conduct audits on claims for medically appropriate services delivered in inpatient settings while adhering to applicable medical review guidelines, policies, and regulations.

• Record all findings with references to the relevant policies and regulations.

• Create letters that clearly communicate the results of the audits.

• Provide support for your findings during the appeals process upon request.

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

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

• Work with the team to reduce the frequency of appeals; propose enhancements to improve audit workflows; assist with quality assurance functions and train team members.

• Participate in cross-training across all clinical departments/areas.

• Perform additional duties as necessary to fulfill business requirements.

⛳️ Requirements

• An associate or bachelor’s degree in nursing (with an active/unrestricted RN license) is mandatory.

• Medical Coding certification is advantageous.

• A minimum of 2 years of experience in Home Health claims auditing, quality assurance, and/or recovery auditing is required.

• Must possess experience in Home Health.

• A strong emphasis on quality and meticulous attention to detail is essential.

• A profound curiosity and analytical skills to comprehend the root causes of events and behaviors are necessary.

• Demonstrated ability to exercise critical judgment in clinical determinations; medical coding proficiency is preferred.

• Comprehensive knowledge of clinical criteria and documentation standards to support code assignments is required.

• Familiarity with ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines is preferred.

• Capability to work independently and effectively in a remote setting.

🏝️ Benefits

• Equal Employment Opportunity at Machinify