Medical Review Nurse (Clinical Validation)

TL;DR

Medical Review Nurse (Clinical Validation): Performing retrospective and prepayment medical claims audits for Government and Commercial Payers with an accent on clinical accuracy, coding compliance, and documentation integrity. Focus on applying medical review guidelines, supporting appeals, and ensuring high-quality audit outcomes in a fast-paced remote environment.

Location: Must be based in the United States

Company

hirify.global is a healthcare intelligence company providing an AI-powered platform to maximize financial outcomes and reduce costs for health plans.

What you will do

• Audit inpatient claims for medical necessity using established guidelines and policies.
• Document findings and generate professional letters articulating audit results.
• Support findings during the appeals process as needed.
• Collaborate with the audit team to identify potential abuse or vulnerabilities.
• Maintain knowledge of medical practice, technology, and regulatory changes.
• Assist with quality assurance functions and cross-train in clinical departments.

Requirements

• Active and unrestricted RN license (Associate or Bachelor’s degree in nursing).
• Minimum 2 years of experience in inpatient claims auditing, quality assurance, recovery auditing, or clinical documentation integrity.
• Required certification: CCDS, CDIP, CCS, or CIC.
• Deep knowledge of ICD-10, CPT-4, HCPCS, and DRG methodologies.
• Experience with utilization management systems like MCG or InterQual.
• Must be based in the US and capable of working independently in a remote setting.

Culture & Benefits

• Work in a dynamic, AI-driven healthcare environment.
• Collaborate with a multi-location team of experienced auditors and coders.
• Opportunity to impact financial outcomes and healthcare efficiency.
• Commitment to equal employment opportunity and inclusive workplace practices.