Machinify

Machinify

Medical Review Nurse - Clinical Validation

Remote - US · Mid

Sponsorship not specifiedDetected 42 days ago
AuditingICD-10CommunicationMicrosoft OfficeSharePoint

About the role

  • 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.
  • 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.

Responsibilities

  • Document all findings referencing the appropriate policies and rules.
  • Support your findings during the appeals process if requested.
  • Ability to maintain high quality work while meeting strict deadlines.
  • Ability to manage multiple tasks including desk audits and claims review.

Requirements

  • An associate or bachelor's degree in nursing (active/unrestricted RN license).
  • Certification (at least one of the following is required):
  • Other duties as required to meet business needs.
  • Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload

Nice to have

  • 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.
  • 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.
  • Equal Employment Opportunity at Machinify

Skills

  • 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.
  • Excellent written and verbal communication skills.
  • Must be able to independently use standard office computer technology (e.g. email SharePoint, slack, outlook calendar etc.)

Compensation

  • In accordance with applicable state laws, we do not inquire about salary history during the recruitment process.

Benefits

  • 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.
  • Auditing claims for medically appropriate services provided for inpatient settings while applying appropriate medical review guidelines, policies and rules.
  • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
  • Education Requirements:

Company info

  • You will work remotely in a fast-paced and dynamic environment and be part of a multi-location team.

Visa & Work Authorization

  • al employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status
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This listing is sourced directly from Machinify's careers page and normalized into a canonical job model.