Medical Review Nurse – CMS/RAC Auditor, Government Audits

Machinify

. Audit claims for medically appropriate inpatient and outpatient services using medical review guidelines, policies, and rules .

Posted 10/14/2026full-timeRemote • United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in medical claims auditing, including ICD-9/ICD-10 coding and medical billing, while effectively collaborating with teams to enhance medical policies and workflows. Possesses strong communication skills and the ability to manage multiple tasks in a fast-paced environment.

Highest-signal resume keywords

Active RN LicenseICD-9/ICD-10 Coding ExpertiseMedical Records Review ExperienceUtilization Management Systems ExperienceExcellent Written and Verbal Communication Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

ICD-9 CodingICD-10 CodingCPT-4 CodingHCPCS CodingMedical BillingClaims ReviewAudit Workflow ImprovementMedical Review GuidelinesDocumentation CreationQuality Assurance

Soft Skills

Excellent CommunicationTask ManagementTeam CollaborationOrganizational SkillsIndependence

Tools & Technologies

Utilization Management SystemsClinical Decision-Making ToolsCase Management SystemsStandard Office Technology

Certifications & Qualifications

Active RN License

Industry Keywords

Medical Claims AuditInpatient ServicesOutpatient ServicesInsurance ProgramsRegulatory IssuesProvider EducationAppeals ProcessAudit Team CollaborationMedical Policies

About the role

Key responsibilities & impact

Audit claims for medically appropriate inpatient and outpatient services using medical review guidelines, policies, and rules
Document findings with references to applicable policies and rules
Generate letters articulating audit findings
Support findings during the appeals process when requested
Collaborate with the audit team to identify and obtain approval for vulnerabilities and potential abuse cases
Partner with clients, CMD colleagues, and contractors to improve medical policies, provider education, and system edits
Monitor medical practice, technology changes, and regulatory issues affecting clients
Help minimize appeals, improve audit workflows, assist with QA, and train team members
Participate in establishing edit parameters, new issue packets, and Medical Review Guidelines
Interface with and support the Medical Director and cross-train across clinical departments
Perform other duties as required by 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 demonstrating expertise in ICD-9/ICD-10 coding, HCPCS/CPT coding, DRG, and medical billing experience for an insurance company or hospital
Experience with utilization management systems or clinical decision-making tools such as MCG or InterQual
Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding
Knowledge of insurance programs, particularly 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
Ability to independently use standard office computer technology and case management systems/tools
Ability to manage multiple assignments, create documentation, and organize and prioritize workload
Ability to work independently and as part of a team in a remote setting

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
Reasonable accommodation during the application or recruitment process
Employment at will
E-Verify participation as required by applicable law