Medical Review Nurse – CMS/RAC Auditor, Government Audits

Machinify

Medical Review Nurse auditing claims for government clients while working remotely with a multi-location team. Engaging in medical review guidelines and ensuring compliance with healthcare regulations.

Posted 6/26/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

About the role

Key responsibilities & impact

Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.
Document all findings referencing the appropriate policies and rules.
Generate letters articulating audit findings.
Supporting 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.
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
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.
Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.
Interface with and support the Medical Director and cross train in all clinical departments/areas.
Other duties as required to meet business needs.

Requirements

What you’ll need

Active unrestricted RN license in good standing, is required.
Must not be currently sanctioned or excluded from the Medicare program by the OIG.
Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.
One (1) or more years' experience performing medical records review.
One (1) or more years' experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required.
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.
RAC certification preferred.

Benefits

Comp & perks

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.
Participation in E-Verify as required by applicable law.
Commitment to reasonable accommodation during the application or recruitment process.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

ICD-9 codingICD-10 codingHCPCS codingCPT codingDRG codingmedical billingutilization reviewmedical records reviewauditingquality assurance

Soft Skills

collaborationcommunicationproblem-solvingcritical thinkingattention to detailorganizational skillstrainingsupportarticulation of findingssuggesting improvements

Certifications

RN licenseRAC certification