Medical Review Nurse - Home Health Auditor
- Location
- Remote (US)
- Job type
- Full-time
- Level
- Senior
- Experience
- 2+ years
- Listed
- 31 days ago
Skills & highlights for this role
- RN license
- BLS
- MCG
- InterQual
- ICD-10-CM
- CPT
- HCPCS
Also useful
- CCDS
- CDIP
- CCS
- CIC
Key Responsibilities
- Auditing claims for medically appropriate services provided for inpatient settings while applying appropriate medical review guidelines, policies and rules.
- Document all findings referencing the appropriate policies and rules.
- Generate letters articulating audit findings.
- Support your findings during the appeals process if requested.
- Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
- Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
- Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members.
- Cross train in all clinical departments/areas.
- Other duties as required to meet business needs.
Knowledge, Skills and Abilities Needed
- 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.
- Knowledge of insurance programs program, particularly the coverage and payment rules.
- Ability to maintain high quality work while meeting strict deadlines.
- Excellent written and verbal communication skills.
- 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
- Effectively work independently and as a team, in a remote setting.
Education Requirements
- An associate or bachelor's degree in nursing (active/unrestricted RN license) is required.
- Medical Coding certification is preferred (see below for examples).
- CCDS - Certified Clinical Documentation Specialist
- CDIP - Clinical Documentation Improvement Practitioner
- CCS - Certified Coding Specialist
- CIC - Certified Inpatient Coder
Required and Preferred Qualifications
- Home Health claims auditing, quality assurance and/or recovery auditing experience of 2 years or more required. Experience of 3 or more years is preferred.
- Must have Home Health experience.
- Strong focus on quality and attention to detail.
- Deep curiosity and analytical skills to understand root causes of events and behaviors.
- Proven ability to apply critical judgment in clinical determinations; medical coding ability preferred.
- In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
- Understanding of ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA's Coding Clinic Guidelines is preferred.
- Ability to work independently and efficiently in a remote environment.
About Machinify
Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. 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. We're constantly reimagining what's possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs.
The Medical Review Nurse II primarily performs medical claims audit reviews with a focus on the Home Health sector. As a MR Nurse Auditor, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government and Commercial Payers. You will work remotely in a fast-paced and dynamic environment and be part of a multi-location team.
Equal opportunity and legal notices
We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law.
In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know.
From Machinify's careers page, first listed on Rolev.ai on October 10, 2026. Rolev.ai is not the employer.
How Rolev.ai helps with this application
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Common questions
Where is the Medical Review Nurse - Home Health Auditor job at Machinify located?
Yes, this Medical Review Nurse - Home Health Auditor opening at Machinify is listed as Remote (US). Always check Machinify's application page for specific state eligibility or relocation policies.
What qualifications are required for Medical Review Nurse - Home Health Auditor at Machinify?
For the Medical Review Nurse - Home Health Auditor role, Machinify highlights 2+ years of relevant experience; experience with MCG, InterQual, ICD-10-CM, CPT, HCPCS. Rolev.ai can score your existing resume against these requirements and show any skill gaps before you apply.
How do I apply for the Medical Review Nurse - Home Health Auditor position at Machinify?
This listing links directly to Machinify's Greenhouse application page. You can apply directly on Machinify's site, or use Rolev.ai to check your resume fit, generate a zero-hallucination tailored resume and cover letter for this posting, and autofill the Greenhouse application form in 1 click with the Rolev.ai Chrome extension. You always review the form and press Submit yourself.