About this role
Role Overview
- 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.
- 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.
- Other duties as required to meet business needs.
Requirements
- 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.
Benefits
- Equal Employment Opportunity at Machinify