Medical Review Nurse - SNF/MDS Auditor

Key Responsibilities

• Auditing claims for medically appropriate services provided in skilled nursing facility 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 audit findings during the appeals process if requested.
• Work collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
• 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.
• Interface with and support the Medical Director and cross train in all clinical departments/areas.

Required Qualifications

• Active unrestricted RN license in good standing, is required.
• 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 with MDS/ RAI process.
• One (1) or more years' experience performing medical records review.
• One (1) or more years' experience in health care claims that demonstrates expertise in ICD-9/ICD-10 coding guidelines and how it relates to the MDS RAI Process.
• Comprehension of the Uniform Medical Billing Form (UB-04) and application to the MDS billing process.

Preferred Qualifications

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
• Strong preference for Understanding and in-depth comprehension of PDPM HIPPS codes including HIPPS Clinical Categories and the components that comprise the HIPPS categories.
• Knowledge of RUG and LOC commercial payors preferred but not required.
• Understanding of Medicare Benefit Payment Manual and Medicare Claims Processing Manual for SNF