Medical Review Nurse - Clinical Validation

Responsibilities

• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support your findings during the appeals process if requested.

Requirements

• Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise.
• Cross train in all clinical departments/areas.
• Other duties as required to meet business needs.
• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. •
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g. email SharePoint, slack, outlook calendar etc.)
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
• An associate or bachelor’s degree in nursing (active/unrestricted RN license).
• Certification (at least one of the following is required):
• CCDS - Certified Clinical Documentation Specialist
• CIC - Certified Inpatient Coder
• experience of 2 years or more required, and/or Inpatient Clinical Documentation Integrity
• experience of 2 years or more required.
• Proven ability to apply critical judgment in clinical and coding determinations.
• In-depth knowledge of clinical criteria and documentation
• Expert in DRG methodologies (e.g., MS & APR).
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.

Benefits