Medical Review Nurse - Home Health Auditor

TL;DR

Medical Review Nurse - Home Health Auditor (Home Health/Claims Auditing): Perform retrospective and prepayment medical claims audit reviews for inpatient services using medical review guidelines, policies, and rules with an accent on Home Health claims, clinical criteria, and accurate documentation. Focus on applying ICD-10-CM/PCS and CPT/HCPCS coding knowledge, generating audit letters, and supporting findings through appeals while improving audit workflows and QA.

Location: Remote (US)

Company

hirify.global is a healthcare intelligence company providing an AI-powered, configurable platform for health plan clients.

What you will do

• Audit medical claims for medically appropriate services in inpatient settings using medical review guidelines, policies, and rules.
• Document audit findings with references to the applicable policies and rules.
• Generate letters that clearly explain audit findings.
• Support audit findings during the appeals process when requested.
• Collaborate with the audit team to identify and obtain approval for vulnerabilities/cases subject to potential abuse.
• Assist with QA functions and training; suggest improvements to audit workflows; cross-train across clinical departments.

Requirements

• Location: Must be based in the US
• Associate or bachelor’s degree in nursing and an active/unrestricted RN license.
• 2+ years of Home Health claims auditing, quality assurance, and/or recovery auditing experience (3+ years preferred).
• Deep knowledge of ICD-9/ICD-10 and CPT-4 or HCPCS coding; strong attention to detail and ability to meet strict deadlines.
• Excellent written and verbal communication skills for documentation and audit letters.
• Ability to independently use standard office technology (email, SharePoint, Slack, calendar) and manage multiple desk audits/claims reviews.

Nice to have

• Medical coding certification (e.g., CCDS, CDIP, CCS, CIC).
• Experience with utilization management systems or clinical decision-making tools such as MCG or InterQual.
• Preferred knowledge of ICD-10-CM/PCS, UHDDS definitions, Official Coding Guidelines, and AHA Coding Clinic Guidelines.

Culture & Benefits

• Remote work in a fast-paced, dynamic environment with a multi-location audit team.
• Focus on quality, attention to detail, and continuous improvement of audit workflows.
• Opportunities to cross-train across clinical departments and support QA and training activities.
• Ongoing monitoring of medical practice, technology, and regulatory changes that affect clients.

Hiring process

• Interviews to assess clinical auditing/coding experience, quality focus, and ability to work independently in a remote setting.
• Evaluation of communication skills through discussion of documentation and audit letter creation.