Medical Review Nurse - CMS/RAC Auditor, Government Audits

Key Responsibilities:

• Auditing claims for medically appropriate services using medical review guidelines and documenting findings with reference to policies.
• Generating letters articulating audit findings and supporting appeals, working collaboratively with the team.

Knowledge, Skills and Abilities Needed:

• Experience with utilization management systems (MCG/InterQual) and deep knowledge of ICD-10, CPT-4, HCPCS coding.
• Excellent communication, ability to manage multiple tasks, and independent use of office technology.

Required and Preferred Qualifications:

• Active unrestricted RN license, minimum 5 years nursing experience, and 1+ year medical records review.
• Experience in healthcare claims with ICD-9/10, HCPCS/CPT coding, DRG and medical billing, plus RAC certification preferred.