Hiring Range: $81,000 - 90,000
The Medical Review Nurse - CMS RAC (Government audits) primarily performs medical claims audit reviews for government clients. 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. You will work remotely in a fast paced and dynamic environment and be part of a multi-location team.
Please note : RAC certification is preferred in this role, though may not be strictly required.
Responsibilities
Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.
Document all findings referencing the appropriate policies and rules.
Generate letters articulating audit findings.
Supporting your findings during the appeals process if requested.
Working 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.
Knowledge, Skills and Abilities Needed:
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.
Ability to maintain high quality work while meeting strict deadlines.
Excellent written and verbal communication skills.
Ability to manage multiple tasks including desk audits and claims review.
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
Effectively work independently and as a team, in a remote setting.
Required and Preferred 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 performing medical records review.
One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
Benefits
Physical Requirements & Additional Notices :If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required . Proof of such may be required prior to an offer being made. It is the Employee's responsibility to maintain this Internet access at their home office location.The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similaHealth insuranceDental insuranceVision insurance401(k)Remote work optionsParental leave
Additional Information
ABOUT MACHINIFY:
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify's AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We're reshaping healthcare payment through seamless intelligence.
Performant · Plantation, FL