Medical Review Nurse II - SNF/MDS Auditor

About the role

Machinify is a leading healthcare intelligence company delivering AI-powered solutions to health plans nationwide. This role focuses on performing Skilled Nursing Facility (SNF) medical claims audit reviews, working remotely as part of a multi-location team.

Responsibilities

• Audit claims for medically appropriate services in skilled nursing facility settings using relevant medical review guidelines, policies, and rules.
• Document all findings with references to applicable policies and rules.
• Generate letters articulating audit findings.
• Support audit findings during the appeals process when requested.
• Collaborate with the audit team to identify vulnerabilities and cases subject to potential abuse.
• Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits.
• Stay current with medical practice changes, technological advancements, and regulatory issues affecting clients.
• Work with the team to minimize appeals and suggest workflow improvements.
• Assist with QA functions and training 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.
• Perform other duties as required to meet business needs.

Requirements

• Active, unrestricted RN license in good standing.
• No current sanctions or exclusions from the Medicare program by the OIG.
• Minimum of five (5) years of diversified nursing experience in inpatient or outpatient settings.
• One (1) or more years of experience with the MDS/RAI process.
• One (1) or more years of experience performing medical records review.
• One (1) or more years of experience in healthcare claims demonstrating expertise in ICD-9/ICD-10 coding guidelines and their relation to the MDS RAI process.
• Understanding of the Uniform Medical Billing Form (UB-04) and its application to the MDS billing process.

Preferred Qualifications

• Experience performing utilization review for an insurance company, Tricare, MAC, or similar organizations.
• In-depth comprehension of PDPM HIPPS codes, including HIPPS Clinical Categories and their components.
• Knowledge of RUG and LOC commercial payors.
• Understanding of Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF.

Pay

This is an exempt salaried position with an expected starting range of $85,000 – $100,000 annually. Actual offered amounts will depend on individual candidate evaluations.