Medical Review Nurse (SNF/MDS)

TL;DR

Medical Review Nurse (SNF/MDS): Performing retrospective and prepayment audits on skilled nursing facility claims with an accent on MDS/RAI process compliance and ICD-10 coding accuracy. Focus on identifying potential abuse, supporting appeals, and collaborating with clinical teams to improve medical policies and system edits.

Location: Must be based in the US

Company

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

What you will do

• Audit claims for medically appropriate services in skilled nursing facility settings.
• Document findings and generate letters articulating audit results.
• Support audit findings during the appeals process.
• Collaborate with the audit team to identify vulnerabilities and potential abuse.
• Partner with clients and clinical colleagues to improve medical policies and provider education.
• Participate in QA functions, training, and the development of medical review guidelines.

Requirements

• Active unrestricted RN license in the US is required.
• Must not be currently sanctioned or excluded from the Medicare program by the OIG.
• Minimum of five years of diversified nursing experience in inpatient or outpatient settings.
• At least one year of experience with the MDS/RAI process.
• At least one year of experience performing medical records review.
• Expertise in ICD-9/ICD-10 coding guidelines and UB-04 billing forms.
• Ability to work independently in a remote setting.

Nice to have

• Experience performing utilization review for insurance companies or MACs.
• In-depth comprehension of PDPM HIPPS codes and clinical categories.
• Knowledge of RUG and LOC commercial payors.
• Understanding of Medicare Benefit Payment and Claims Processing Manuals.

Culture & Benefits

• Work in a fast-paced, dynamic, and remote environment.
• Opportunity to work with a multi-location team of experienced medical auditors.
• Engagement with AI-powered healthcare technology.
• Commitment to equal employment opportunity and inclusive workplace culture.