Remote Medical Review Nurse—CMS/RAC Audits

Machinify; Oregon; Hybrid; USD 85,000 - 120,000; Full time

Job summary

Machinify is seeking a Medical Review Nurse to conduct CMS/RAC audits for government payers. This remote role involves reviewing claims for medical necessity in inpatient and outpatient settings, documenting findings, and supporting appeals.

RAC certification is preferred and encouraged if not already held. The candidate will work with a multidisciplinary team, stay updated on regulatory changes, and contribute to policy improvements while meeting tight deadlines in a fast-paced, remote

Qualifications

• Active unrestricted RN license in good standing.
• Minimum of five (5) years diversified nursing experience in inpatient or outpatient settings.
• One (1) or more years' experience performing medical records review.
• One (1) or more years' experience in health care claims with ICD-9/ICD-10, HCPCS/CPT coding, DRG and medical billing.

Responsibilities

• Auditing claims for medically appropriate services in inpatient and outpatient settings.
• Documenting findings with reference to policies and rules.
• Generate audit letters and support during appeals as needed.
• Collaborate with audit team to identify vulnerabilities and improvements.
• Interface with clients and cross train in clinical departments.
• Stay current with medical practices, technology changes, and regulatory issues.

Skills

Nursing experience

Medical records review

ICD-9/ICD-10 coding

CPT/HCPCS coding

Utilization management

Education

RN license

Tools

Case management software

Job description

Machinify is seeking a Medical Review Nurse to conduct CMS/RAC audits for government payers. This remote role involves reviewing claims for medical necessity in inpatient and outpatient settings, documenting findings, and supporting appeals.

RAC certification is preferred and encouraged if not already held. The candidate will work with a multidisciplinary team, stay updated on regulatory changes, and contribute to policy improvements while meeting tight deadlines in a fast-paced, remote