Medical Review Nurse II – SNF/MDS Auditor

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

📋 Description

• Conduct audits on claims for medically appropriate services delivered in skilled nursing facility environments, adhering to applicable medical review guidelines, policies, and regulations.

• Record audit results with references to pertinent policies and regulations.

• Create letters that clearly articulate audit findings.

• Provide support for audit findings during appeals when requested.

• Collaborate with the audit team to identify and secure approval for vulnerabilities or potential abuse cases.

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

• Keep track of changes in medical practice, technology, and regulatory issues that impact clients.

• Assist in reducing appeals and recommend improvements to the audit workflow.

• Support quality assurance activities and train team members.

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

• Provide assistance to the Medical Director and participate in cross-training across clinical departments and areas.

• Perform additional duties as necessary to fulfill business needs.

⛳️ 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 years of varied nursing experience delivering direct care in inpatient or outpatient settings is required.

• At least one year of experience with the MDS/RAI process.

• A minimum of one year of experience in medical records review.

• At least one year of healthcare claims experience demonstrating proficiency in ICD-9/ICD-10 coding guidelines and their connection to the MDS/RAI process.

• Understanding of the Uniform Medical Billing Form (UB-04) and its relevance to the MDS billing process.

• Experience and extensive knowledge of ICD-9, ICD-10, and HCPCS coding.

• Familiarity with PDPM payment items that contribute to payment methodologies.

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

• Exceptional written and verbal communication skills.

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

• Proficiency in working independently with Microsoft Word, Excel, and PowerPoint, including document and spreadsheet management.

• Skill in managing multiple assignments, documenting findings or suggestions, and organizing and prioritizing workload.

• Capability to work both independently and collaboratively as part of a team in a remote environment.

• Preferred: experience in utilization review for an insurance company, Tricare, MAC, or similar organization.

• Preferred: comprehensive understanding of PDPM HIPPS codes, clinical categories, and component calculations.

• Preferred: knowledge of RUG and LOC commercial payors.

• Understanding of the Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF.

🏝️ Benefits

• Opportunity for remote work.

• Exempt salaried position.

• Equal employment opportunity.

• Reasonable accommodations available during the application or recruitment process.