Medical Review Nurse - CMS/RAC Auditor, Government Audits

About the role

Machinify is a leading healthcare intelligence company delivering unmatched value, transparency, and efficiency to health plan clients across the country. The Medical Review Nurse - CMS / RAC (Government Audits) primarily performs medical claims audit reviews for government clients. As a Medical Review Nurse, you will join a remote, multi-location team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government Payers. RAC certification is preferred; the selected candidate may need to work toward RAC certification if they do not currently have it.

Responsibilities

• Audit claims for medically appropriate services in inpatient and outpatient settings while applying medical review guidelines, policies, and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support findings during the appeals process if requested.
• Collaborate with the audit team to identify and obtain approval for vulnerabilities and cases subject to potential abuse.
• Partner with clients, colleagues, and contractors to improve medical policies, provider education, and system edits.
• Stay current with medical practice, technology changes, and regulatory issues affecting clients.
• Work to minimize appeals and suggest improvements to audit workflows.
• Assist with QA functions and train 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.
• Perform other duties as required to meet business needs.

Requirements

• Active unrestricted RN license in good standing.
• 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 performing medical records review.
• One (1) or more years' experience in healthcare claims demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing for an Insurance Company or hospital.
• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or similar organizations.
• RAC certification preferred.

Skills

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
• Knowledge of insurance programs, particularly 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.
• Proficiency with standard office computer technology (e.g., email, telephone, copier) and case management systems/tools.
• Ability to work independently and as part of a remote team.