Remote RN Medical Review Auditor – Claims & DME

Machinify; Oregon; Híbrido; USD 70.000 - 90.000; Jornada completa

Descripción de la vacante

Machinify is seeking a Medical Review Nurse II - Commercial DME to audit medical claims for appropriate services in inpatient and outpatient settings. This remote role supports government and commercial payers in a fast-paced, cross-functional team.

You will document findings, generate audit letters, and assist during appeals while staying current with medical review guidelines and coding standards. RN license required; 5+ years nursing experience encouraged.

Formación

• Active unrestricted RN license in good standing.
• Minimum five (5) years of diversified nursing experience providing direct care in inpatient or outpatient settings.
• One or more years of experience in medical records review.
• One or more years of experience in health care claims coding (ICD-9/ICD-10, HCPCS/CPT) for an insurance company or hospital preferred.

Responsabilidades

• Audit claims for medically appropriate services in inpatient and outpatient settings.
• Document findings referencing policies and rules.
• Generate letters articulating audit findings.
• Support findings during appeals if requested.
• Collaborate with the audit team to identify vulnerabilities and cases needing approval.
• Work with clients, CMD colleagues, and other contractors to improve medical policies, provider education, and system edits.
• Keep abreast of medical practice changes and regulatory issues.
• Assist with QA functions and training team members.
• Interface with the Medical Director and cross-train in clinical areas.
• Other duties as required to meet business needs.

Conocimientos

RN license

Healthcare claims review

ICD-9/ICD-10 coding

HCPCS/CPT coding

Utilization management knowledge

Communication skills

Descripción del empleo

Machinify is seeking a Medical Review Nurse II - Commercial DME to audit medical claims for appropriate services in inpatient and outpatient settings. This remote role supports government and commercial payers in a fast-paced, cross-functional team.

You will document findings, generate audit letters, and assist during appeals while staying current with medical review guidelines and coding standards. RN license required; 5+ years nursing experience encouraged.