Medical Review Nurse II - SNF/MDS Auditor

TL;DR

Medical Review Nurse II - SNF/MDS Auditor (SNF/MDS): Auditing skilled nursing facility claims for government and commercial payers with an accent on MDS/RAI processes, coding accuracy, and payment methodology. Focus on validating medical necessity, documenting findings, supporting appeals, and developing medical review guidelines and system edits.

Location: Remote within the United States; the role requires an active unrestricted RN license and eligibility to work with Medicare-related claims.

Salary: $85,000–$100,000 annually; exempt salaried position.

Company

Healthcare intelligence company providing an AI-powered platform and expertise for improving payment outcomes and reducing healthcare costs for health plan clients.

What you will do

• Perform retrospective and prepayment audits of skilled nursing facility claims using applicable medical review guidelines, policies, and rules.
• Document audit findings, prepare determination letters, and support findings during appeals.
• Identify claim vulnerabilities and potential abuse cases with the audit team and obtain appropriate approvals.
• Collaborate with clients, medical directors, clinical colleagues, and contractors on medical policies, provider education, and system edits.
• Help develop edit parameters, issue packets, and medical review guidelines while improving audit workflows.
• Support quality assurance, team training, and cross-functional clinical initiatives.

Requirements

• Active, unrestricted RN license in good standing is required.
• Must not be sanctioned or excluded from the Medicare program by the OIG.
• At least five years of diversified nursing experience providing direct inpatient or outpatient care.
• At least one year of experience with the MDS/RAI process, medical records review, and healthcare claims involving ICD-9/ICD-10 coding.
• Knowledge of PDPM payment items, HIPPS codes, SNF billing, and the UB-04 form.
• Ability to manage multiple assignments independently, meet strict deadlines, document findings clearly, and collaborate effectively in a remote environment.

Nice to have

• Utilization review experience with an insurance company, TRICARE, MAC, or similar organization.
• In-depth understanding of PDPM HIPPS clinical categories and their components.
• Knowledge of RUG and LOC for commercial payers.
• Understanding of the Medicare Benefit Policy Manual and Medicare Claims Processing Manual for SNFs.

Culture & Benefits

• Fully remote work within the United States.
• Fast-paced, dynamic environment with a multi-location audit team.
• Opportunity to collaborate with health plan clients and clinical leaders on improving healthcare payment processes.
• Exempt salaried employment with compensation based on individual candidate evaluation.