Remote RN - Medical Review Appeals Auditor

Precision Labs; Northern (KY); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Machinify is seeking a Medical Review Clinical Appeals Auditor (RN) to conduct Appeals reviews of new evidence in medical review audits and support training and guideline materials. The role emphasizes maintaining expert knowledge of medical practice, CMS/Medicaid/Commercial rules, and a strong emphasis on quality and productivity.

The candidate will document results, analyze claims data, and collaborate with leadership to improve audit outcomes, while ensuring confidentiality and adherence to

Qualifications

• Active unrestricted RN license required.
• Minimum 5+ years in SNF/MDS or payer auditing.
• Experience with CPT/HCPCS/ICD-9/ICD-10 coding may be necessary.

Responsibilities

• Perform clinical reviews on medical records to maintain subject matter expertise.
• Conduct Appeals reviews on audit work with new evidence from auditees.
• Document Appeals results in accordance with quality policies and procedures.
• Review audit documentation, analyze claims data, and apply guidelines to determine audit results.
• Provide corrective narrative and flag patterns for leadership intervention.
• Assist in continuous improvement of audit guidelines, tools, and training.

Skills

Nursing auditing

Medical records review

CMS/MediCare knowledge

Data analysis

Education

RN license (unrestricted)

BSN or higher

Tools

EHR systems

Encoder

Claims data analysis tools

Job description

Machinify is seeking a Medical Review Clinical Appeals Auditor (RN) to conduct Appeals reviews of new evidence in medical review audits and support training and guideline materials. The role emphasizes maintaining expert knowledge of medical practice, CMS/Medicaid/Commercial rules, and a strong emphasis on quality and productivity.

The candidate will document results, analyze claims data, and collaborate with leadership to improve audit outcomes, while ensuring confidentiality and adherence to