Medical Review Nurse II - Government/Clinical Outpatient Focus
About the position The Medical Review Nurse II - Government/Clinical Outpatient Focus primarily performs medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team. Responsibilities • Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. • Document all findings referencing the appropriate policies and rules. • Generate letters articulating audit findings. • Supporting your findings during the appeals process if requested. • Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. • Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. • Work with the team to minimize the number of appeals; • Suggest ideas that may improve audit workflows; • Assist with QA functions and training team members. • Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. • Interface with and support the Medical Director and cross train in all clinical departments/areas. • Other duties as required to meet business needs. Requirements • Active unrestricted RN license in good standing, is required. • Must not be currently sanctioned or excluded from the Medicare program by the OIG. • Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting. • One (1) or more years' experience performing medical records review. • One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. • Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. • Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding. • Knowledge of insurance programs program, particularly the coverage and payment rules. • Ability to maintain high quality work while meeting strict deadlines. • Excellent written and verbal communication skills. • Ability to manage multiple tasks including desk audits and claims review. • Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings. • Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload • Effectively work independently and as a team, in a remote setting. Nice-to-haves • Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions. Benefits • Machinify offers a wide range of benefits to help support a healthy work/life balance. • These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. Apply tot his job