Medical Review Nurse II – SNF/MDS Auditor

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

📋 Description

• Review claims for medically appropriate services rendered in skilled nursing facilities, utilizing medical review guidelines, policies, and regulations.

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

• Create letters that clearly convey audit findings.

• Provide support for audit conclusions during the appeals process when necessary.

• Collaborate with the audit team to pinpoint and secure approval for vulnerabilities and possible abuse cases.

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

• Keep track of changes in medical practices, technology, and regulatory matters impacting clients.

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

• Contribute to QA functions and train team members.

• Engage in setting edit parameters, creating new issue packets, and developing Medical Review Guidelines.

• Support and collaborate with the Medical Director while cross-training across clinical departments.

• Perform other tasks as necessary to fulfill business requirements.

⛳️ 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 either inpatient or outpatient environments.

• At least one (1) year of experience with the MDS/RAI process.

• A minimum of one (1) year of experience conducting medical records reviews.

• At least one (1) year of experience in health care claims, 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 application to the MDS billing process.

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

• Familiarity with PDPM payment components that influence payment methodologies.

• Capacity to work independently using Microsoft Office applications, including Word, Excel, and PowerPoint.

• Skill in managing multiple tasks, documenting findings, and organizing and prioritizing workload.

• Ability to work autonomously and collaboratively as part of a remote team.

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

• Exceptional written and verbal communication skills.

🏝️ Benefits

• Comprehensive health insurance options.

• Retirement savings plan with employer matching.

• Opportunities for professional development and advancement.

• Flexible work hours to promote work-life balance.

• Supportive and collaborative team environment.