Medical Review Nurse - Clinical Validation

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. As a MR Nurse, 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. 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...