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Medical Review Nurse - Clinical Validation
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.
The Medical Review Nurse II 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.
Key Responsibilities:
- Auditing claims for medically appropriate services provided for inpatient 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 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.
- 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.
- Cross train in all clinical departments/areas.
- Other duties as required to meet business needs.
Knowledge, Skills and Abilities Needed:
- 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 SharePoint, slack, outlook calendar etc.)
- 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.
Education Requirements:
- An associate or bachelor’s degree in nursing (active/unrestricted RN license).
Certification (at least one of the following is required):
- CCDS - Certified Clinical Documentation Specialist
- CDIP - Clinical Documentation Improvement Practitioner
- CCS - Certified Coding Specialist
- CIC - Certified Inpatient Coder
Required and Preferred Qualifications:
- Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more required.
- Strong focus on quality and attention to detail.
- Deep curiosity and analytical skills to understand root causes of events and behaviors.
- Proven ability to apply critical judgment in clinical and coding determinations.
- In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
- Expert in DRG methodologies (e.g., MS & APR).
- Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.
- Ability to work independently and efficiently with minimal supervision.
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