Medical Review Nurse – SNF/MDS Auditor

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

📋 Description

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

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

• Prepare letters that detail the findings of the audits.

• Provide support for audit findings during the appeals process if needed.

• Collaborate with the audit team to identify and secure approval for specific vulnerabilities and/or cases that may indicate potential 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 that could enhance audit workflows.

• Assist with quality assurance functions and provide training to team members.

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

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

• Perform other duties as necessary to fulfill business requirements.

⛳️ Requirements

• A valid and unrestricted RN license in good standing is mandatory.

• Must not be currently sanctioned or excluded from the Medicare program by the OIG.

• At least five (5) years of diverse nursing experience providing direct patient care in either inpatient or outpatient settings.

• A minimum of one (1) year of experience with the MDS/RAI process.

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

• One (1) year or more of experience in healthcare claims demonstrating proficiency in ICD-9/ICD-10 coding guidelines and their relevance to the MDS RAI Process.

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

🏝️ Benefits

• Equal Employment Opportunity at Machinify