Medical Review Nurse, Clinical Appeals Auditor

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.

Please read the description and requirements carefully. This role requires specific MDS experience, so if you do not have that experience then please consider applying for one of our other Medical Review Nurse roles, which may be a better fit for you. Thank you!

The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditee’s, disputing all or part of the findings from medical review audit work completed by the medical review clinical audit team members, as well as communicate and support the identification of potential training opportunities or enhancements to training and/or concept review guideline materials and tools. The Appeals Auditor is also responsible for consistently achieving or exceeding productivity goals and quality standards and serves as a subject matter expert, providing supplemental escalation support, and may perform special project activity as needed.
Key Responsibilities

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Performs clinical reviews on medical records to maintain subject matter expertise.

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Conducts Appeals reviews on medical review audit work completed by the medical review clinical and documentation audit team members, as new evidence is presented by auditees.

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Objectively and accurately documents Appeals results in accordance with department quality policies and procedures, scoring and reporting all Appeals results and routes the result appropriately within audit platform based upon how the Appeal review resulted in a full or partial upholding of the audit finding or with a full or partial overturn.

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Reviews audit documentation and conducts research, analyzes claims data, applies knowledge of client SOW, applicable concept guidelines, policies, and regulations as necessary to determine if audit result is accurate and includes complete details to support findings.

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Provides correction to narrative rationale to correspond with audit determination and flags patterns of concern to audit leadership for real-time intervention, preventing an accumulation of improper findings.

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Contributes to the continuous improvement feedback process and suggests any edits to documentation, enhancements review guidelines, and reporting as may be necessary in accordance with department process and audit leadership direction.

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May support findings during the appeals process, if needed.

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May perform primary audit activity as assigned by management.

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Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction.

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May prepare reports for management that includes a variety of data and trends at the individual, department, and client program level, as well as date range or concept based/trended, or other characteristic that will provide valuable business insights.

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Consults with internal resources as necessary.

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Become subject matter expert for assigned business segment(s).

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Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.

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Participates in and contributes to applicable department meetings.

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Successfully completes, retains, applies, and adheres to content in required training as assigned that includes but not limited to information security, anti-harassment and other compliance and p