Medical Review Nurse (Government Audits)

TL;DR

Medical Review Nurse (Government Audits): Performing medical claims audit reviews for government clients with an accent on applying medical review guidelines and documenting findings. Focus on auditing inpatient and outpatient services, reducing appeals, and improving medical policies.

Location: Remote (US)

Company

hirify.global is a leading healthcare intelligence company that utilizes 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 inpatient and outpatient settings using medical review guidelines and policies.
• Document all audit findings and generate formal letters articulating the results.
• Support audit findings during the appeals process and collaborate with teams to identify potential abuse or vulnerabilities.
• Partner with clients and colleagues to improve medical policies, provider education, and system edits.
• Stay current with medical practices, technology changes, and regulatory issues affecting clients.
• Assist with QA functions, train team members, and help establish Medical Review Guidelines and edit parameters.

Requirements

• Active unrestricted RN license in good standing.
• Must not be currently sanctioned or excluded from the Medicare program by the OIG.
• Minimum of 5 years of diversified nursing experience in inpatient or outpatient settings.
• 1+ year of experience performing medical records review.
• 1+ year of expertise in ICD-9/ICD-10, HCPCS/CPT coding, DRG, and medical billing for an insurance company or hospital.
• Must be based in the US (E-Verify participant).

Nice to have

• Experience performing utilization review for an insurance company, Tricare, MAC, or similar organizations.
• RAC certification.

Culture & Benefits

• Fully remote work environment as part of a multi-location team.
• Opportunity to work with a leading AI-powered healthcare intelligence platform.
• Commitment to equal employment opportunity and a diverse workplace.
• Fast-paced and dynamic professional environment.