Machinify este o companie de platforme și servicii de inteligență artificială pentru domeniul sănătății, axată pe îmbunătățirea integrității plăților pentru planurile de sănătate. Sistemul său de operare bazat pe inteligență artificială reunește cereri de despăgubire, dosare medicale, contracte și politici, combinând modele fundamentale cu agenți specializați în sarcini pentru a sprijini codificarea, acuratețea plăților, recuperările și evitarea costurilor. Machinify oferă implementări interne, hibride și complet gestionate, deservește peste 85 de clienți și acoperă 270 de milioane de membri. Compania raportează economii de costuri și recuperări anuale de peste 6 miliarde de dolari.
Medical Review Nurse and CMS/RAC Auditor
Review inpatient and outpatient claims for government payers, support appeals, and help improve audit policies and workflows. Join Machinify’s healthcare intelligence team in this remote U.S. role.
Descriere
- Review inpatient and outpatient claims for medical appropriateness against review guidelines, policies, and rules.
- Record findings and cite the relevant policies and rules.
- Draft letters that explain audit findings.
- Support audit findings during appeals when requested.
- Work with the audit team to identify vulnerabilities and potential abuse cases and seek approval to pursue them.
- Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits.
- Track changes in medical practice, technology, and regulation that affect clients.
- Help reduce appeals, improve audit workflows, support quality assurance, and train team members.
- Help establish edit parameters, new issue packets, and Medical Review Guidelines.
- Work with and support the Medical Director, and cross-train across clinical departments.
- Handle other duties as business needs require.
Cerințe
- Hold an active, unrestricted RN license in good standing.
- Not be currently sanctioned or excluded from Medicare by the OIG.
- Have at least five years of varied nursing experience providing direct care in an inpatient or outpatient setting.
- Have at least one year of medical records review experience.
- Have at least one year of healthcare claims experience, with expertise in ICD-9/ICD-10 and HCPCS/CPT coding, DRGs, and medical billing for an insurer or hospital.
- Have experience with utilization management systems or clinical decision tools such as MCG or InterQual.
- Have deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
- Know insurance programs, particularly coverage and payment rules.
- Maintain high-quality work while meeting strict deadlines.
- Communicate effectively in writing and verbally.
- Manage multiple tasks, including desk audits and claims review.
- Use standard office computer technology and case management systems or tools independently.
- Manage multiple assignments, prepare documentation, and organize and prioritize workload.
- Work independently and collaboratively in a remote setting.
Beneficii
- Equal 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.
- Reasonable accommodation during the application or recruitment process.
- Employment is at will.
- Participation in E-Verify as required by applicable law.