Medical Review Nurse II - SNF/MDS Auditor

Machinify; Oregon; Hybrid; USD 90,000 - 105,000; Full time

Job summary

Machinify, a leading healthcare intelligence company, is seeking a Medical Review Nurse II - SNF/MDS to join a remote audit team. You will perform retrospective and prepayment audits on claims for Government and Commercial Payers in skilled nursing facility settings.

This exempt, salaried role requires RN licensure, 5+ years nursing experience, and strong knowledge of ICD-9/ICD-10, MDS/RAI, and UB-04. You will document findings, support appeals, and collaborate with clients and colleagues to

Qualifications

• Active unrestricted RN license required.
• Not currently sanctioned or excluded from Medicare program by OIG.
• Minimum of five (5) years diversified nursing experience in inpatient or outpatient settings.
• One (1) or more years' experience with MDS/RAI process.
• One (1) or more years' experience performing medical records reviews.
• One (1) or more years' experience in health care claims with ICD-9/ICD-10 guidelines and MDS/RAC process.
• Understanding of UB-04 and its application to MDS billing.

Responsibilities

• Audit claims for medically appropriate services in SNF settings.
• Document findings referencing policies and rules.
• Generate letters detailing audit findings.
• Support audit findings during appeals when requested.
• Collaborate with audit team and clients to improve workflows.
• Keep current with medical practice, technology, and regulatory changes.
• Assist with QA and training of team members.

Skills

Active RN license

MDS/RAI experience

ICD-9/ICD-10 coding

MS Office proficiency

Time management

Communication skills

Remote work

Education

Nursing degree

Tools

UB-04 familiarity

Job description

Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.

Thank you!

Job Summary

The Medical Review Nurse II - SNF/MDS primarily performs Skilled Nursing Facility (SNF) medical claims audit reviews. As a MR Nurse, you will join a team of experienced medical auditors 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.

Pay range

This is an exempt salaried position with an expected starting range of $90,000 - 105,000 annually. Actual offered amounts will be dependent on individual candidate evaluations.

Key Responsibilities

• Auditing claims for medically appropriate services provided in skilled nursing facility settings while applying appropriate medical review guidelines, policies and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support audit findings during the appeals process if requested.
• Work 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.

Knowledge, Skills and Abilities Needed

• Experience with and deep knowledge of ICD-9, ICD-10, HCPCS coding.
• Knowledge of PDPM payment Items contributing to payment methodologies.
• 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 work within Microsoft Office products including Word, Excel, PPT, to Include creating/saving documents in folders, setting up and utilizing spreadsheets, copying and pasting data from one document to another.
• 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.

Required Qualifications

• 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 with MDS/ RAI process.
• 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 guidelines and how it relates to the MDS RAI Process.
• Comprehension of the Uniform Medical Billing Form (UB-04) and application to the MDS billing process.

Preferred Qualifications

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• Strong preference for Understanding and in-depth comprehension of PDPM HIPPS codes including HIPPS Clinical Categories and the components that comprise the HIPPS categories.
• Knowledge of RUG and LOC commercial payors preferred but not required.
• Understanding of Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF

Equal Employment Opportunity at Machinify

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know.