medical claims auditor

Hoag Health System

<div>Primary Duties and Responsibilities
The Claims Auditor is responsible for performing pre-payment and post-payment audits ensuring financial and processing accuracy, compliance with regulatory and health plan requirements of claims processed.
The Claims Auditor is responsible for auditing and confirming accuracy of the loading of:
<ul><li>Fee schedules
</li><li>Provider contracts
</li><li>Payor contracts
</li><li>Benefits
</li><li>Code changes
</li><li>System enhancements</li></ul></div>
 <div>Education and Experience
<ul><li>High School Diploma or equivalent
</li><li>5 years of experience in a medical claims processing environment
</li><li>Knowledge of HMO/managed care regulatory guidelines
</li></ul>Preferred:
<ul><li>Experience with Epic Tapestry system
</li><li>3 years experience in claim audits, revenue recovery, or claims system configuration
</li></ul>License Required
N/A
License Preferred
N/A
Certifications Required
N/A
Certifications Preferred
N/A</div>

Claims Auditor: Hoag Clinic Claims & Enrollment

Western Growers Family of Companies

<div><div>If you&rsquo;re looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we&rsquo;re looking for you.</div><div>
At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.</div><div>
As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn&rsquo;t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee&rsquo;s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.</div><div>
With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees&rsquo; job satisfaction and success.</div><div>
Compensation: $45,091 - $63,617 with a rich benefits package that includes profit-sharing</div><div></div><div><h1 class="jobSectionHeader">
Job Description Summary</h1><div>
Position reports to the Supervisor, Benefit Installation &amp; Distribution and performs in-depth plan coding and testing of new and existing business accounts. This position will ensure that all new and existing health (medical/dental) insurance plans underwritten by the Western Growers Assurance Trust (WGAT) and those of Pinnacle, Inc. (PCMI) are in compliance with the respective employers&rsquo; summary plan descriptions.
</div><h1 class="jobSectionHeader">Qualifications</h1><ul><li>
BS/BA degree in Business or related field and a minimum of three (3) to (5) five years of recent experience as a medical/dental claims auditor or plan testing experience, preferred.
</li><li>Exceptional understanding and ability to interpret summary plan descriptions of employee medical/dental benefits.
</li><li>Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demandingenvironment to meet expected goals, dates, and milestones.</li></ul><ul><li>
 Ability to anticipate problems, recommend solutions, and exercise best judgement.</li><li>
Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.</li><li>
Proficient ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.
</li><li>Previous experience with conducting research and presenting complex information.</li><li>
Excellent communication and interpersonal skills.</li><li>
Superior organization skills and high attention to detail.</li><li>
Ability to learn complex business processes and appropriately apply knowledge to make informed decisions.</li><li>
Advanced skills in Microsoft Office applications.</li><li>
Knowledge of medical terminology. Familiar with ICD10, CPT, HCPC, and CDT codes.</li><li>
Internet access provided by a cable or fiber provider with 40 MB download and 10 MB upload speeds.</li><li>
Home router with wired Ethernet (wireless connections and hotspots are not permitted).</li><li>
A designated room for your office or steps taken to protect company information (e.g., facing computer towards wall, etc.)</li><li>
A functioning smoke detector, fire extinguisher, and first aid kit on site.</li></ul><div>
 Duties And Responsibilities</div><div>
Testing</div><ul><li>
Using close and comprehensive analyses, verify new and existing plans loaded on the Company&rsquo;s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.
</li><li>Test all new plans prior to loading them into production (medical, dental and vision plans).
</li><li>Work with programmers to test claims and related system programs to verify impact within the HCPS.</li><li>
System analysis and testing of mass system updates.</li><li>
Plan coding of new business and plan changes for medical, dental, and vision plans.</li><li>
Communicate with other operational departments, as necessary, to ensure smooth integration of new plans for both WGAT and PCMI moving into production.</li></ul><div>
Reporting</div><ul><li>
Provide monthly reporting of all requested plan issues submitted from the Claims department.</li><li>
Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
</li><li>Create and document Standard Operating Procedures (SOP).</li><li>
Identify, initiate and implement process improvements and/or innovation.</li></ul><div>
Other</div><ul><li>
Utilize all capabilities to satisfy one mission &mdash; to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.</li><li>
Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.</li><li>
Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.</li><li>
Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit)</li><li>
All other duties as assigned.</li></ul>
Physical Demands/Work Environment<div>
The physical demands and work environment described here are representative of those that must be met by an employee to perform the essential functions of this job successfully. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.</div></div></div>

Implementation Auditor

<div><div>If you&rsquo;re looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we&rsquo;re looking for you.</div><div>
At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.</div><div>
As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn&rsquo;t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee&rsquo;s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.</div><div>
With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees&rsquo; job satisfaction and success.</div><div>
Compensation: $44,669.10 - $65,668.60 with a rich benefits package that includes profit-sharing.</div><div></div><div>
JOB DESCRIPTION SUMMARY</div><div>
Position reports to the Supervisor Benefit Distribution &amp; Installation and performs in-depth pharmacy and medical plan coding of new and existing business accounts. This position will ensure that all new and existing health (medical/dental/pharmacy) insurance plans underwritten by Western Growers Assurance Trust (WGAT) and those of Pinnacle Claims Management, Inc. (PCMI) are in compliance with the respective employers&rsquo; summary plan descriptions.</div><div></div><div>
QUALIFICATIONS</div><ul><li>BS/BA degree in computer science, business or related field and a minimum of two years of experience as a pharmacy, medical, dental claims auditor and/or plan testing experience, preferred.</li><li>Exceptional ability to interpret summary plan descriptions of employee medical, dental, pharmacy benefits.</li><li>Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demanding environment to meet expected goals, dates, and milestones.</li><li>Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.</li><li>Superior ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.</li><li>Advanced skills in Microsoft Office applications, specifically word processing and spreadsheets.</li><li>Demonstrated ability to analyze and comprehend complex issues, and personalities using independent judgment, leadership, tact, diplomacy, and initiative.</li></ul><div>
</div><div>
DUTIES AND RESPONSIBILITIES
</div><div>Plan Coding</div><ul><li>Plan code new business and plan changes.</li><li>Verify new and existing plans loaded on the company&rsquo;s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.</li><li>Respond to work orders received from examiners to investigate plan issues and irregularities.</li><li>Evaluate testing requests for all new plans prior to loading them into the production system.</li></ul><div>
Administrative</div><ul><li>Keep a detailed log of open and completed work</li><li>Document resolutions to closed work orders.</li><li>Add to Process management and Maintenance role:</li><li>Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.</li><li>Create and document a minimum of one new Standard Operating Procedure (SOP) annually.</li><li>Identify, initiate and implement at least one process improvement and/or innovation annually.</li><li>Maintain detailed log of plans that are currently being coded and in the process of being loaded.</li><li>Send confirmations to internal stakeholders when applicable plans have been loaded. Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS).</li></ul><div></div><div>
Other</div><ul><li>Utilize all capabilities to satisfy one mission &mdash; to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.</li><li>All other duties as assigned.</li></ul><div>
</div><div>
PHYSICAL DEMANDS/WORK ENVIRONMENT</div><div>
The physical demands and work environment described here represent those that an employee must meet to perform this job&rsquo;s essential functions successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.</div></div>

Plan Coder

Pinnacle Claims Management

<div>
 
 Description
 
 
 
 If you&rsquo;re looking for a career that provides affordable health benefit solutions to the people who support some of the most vital industries, we&rsquo;re looking for you.
 
 
 At Pinnacle Claims Management, we are an innovative third-party administrator (TPA) that provides a full suite of comprehensive and customized health benefits administration services for self-funded companies, including health management and wellness solutions, and pharmacy benefit management. As part of the Western Growers Family of Companies, we are committed to providing our employees with everything they need to succeed and grow. We know that taking care of our clients starts with taking care of our employees.
 
 
 As a keystone of our philosophy, we recognize that every person on our team comes to us with a unique background, history and story that adds strength to our organization. Additionally, employees are encouraged to recognize that there isn&rsquo;t a work life and a home life, there is one life. This recognition throughout the organization emphasizes the value of finding a healthy and happy balance in every employee&rsquo;s life. One way this is realized for employees of Pinnacle Claims Management is flexible work arrangements with work-from-home, in-office or hybrid options.
 
 
 With competitive compensation packages, premier investment support, enriching personal development and more, we strive for our employees&rsquo; job satisfaction and success.
 
 
 
 Compensation: $44,669.10 - $65,668.60 with a rich benefits package that includes profit-sharing.
 
 
 
 
 Job Description Summary
 
 
 
 Position reports to the Supervisor Benefit Distribution &amp; Installation and performs in-depth pharmacy and medical plan coding of new and existing business accounts. This position will ensure that all new and existing health (medical/dental/pharmacy) insurance plans underwritten by Western Growers Assurance Trust (WGAT) and those of Pinnacle Claims Management, Inc. (PCMI) are in compliance with the respective employers&rsquo; summary plan descriptions.
 
 
 
 Qualifications
 
 
 
 <ul>
 <li>
 BS/BA degree in computer science, business or related field and a minimum of two years of experience as a pharmacy, medical, dental claims auditor and/or plan testing experience, preferred.
 </li>
 <li>
 Exceptional ability to interpret summary plan descriptions of employee medical, dental, pharmacy benefits.
 </li>
 <li>
 Strong ability to work efficiently and effectively in a multiple task, multi-project, and multi-demanding environment to meet expected goals, dates, and milestones.
 </li>
 <li>
 Excellent writing, editing, and proofreading skills to compose and edit correspondence, reports, emails, and other written materials.
 </li>
 <li>
 Superior ability to analyze and interpret group health benefits provisions, administrative policies, and provider contracts.
 </li>
 <li>
 Advanced skills in Microsoft Office applications, specifically word processing and spreadsheets.
 </li>
 <li>
 Demonstrated ability to analyze and comprehend complex issues, and personalities using independent judgment, leadership, tact, diplomacy, and initiative.
 
 
 </li>
 </ul>
 
 Duties And Responsibilities
 
 
 
 Plan Coding
 
 
 <ul>
 <li>
 Plan code new business and plan changes.
 </li>
 <li>
 Verify new and existing plans loaded on the company&rsquo;s claim management system against the appropriate Summary Plan Description to determine the accuracy of present and future claims payments.
 </li>
 <li>
 Respond to work orders received from examiners to investigate plan issues and irregularities.
 </li>
 <li>
 Evaluate testing requests for all new plans prior to loading them into the production system.
 
 
 </li>
 </ul>
 Administrative
 
 
 <ul>
 <li>
 Keep a detailed log of open and completed work
 </li>
 <li>
 Document resolutions to closed work orders.
 </li>
 <li>
 Add to Process management and Maintenance role:
 </li>
 <li>
 Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.
 </li>
 <li>
 Create and document a minimum of one new Standard Operating Procedure (SOP) annually.
 </li>
 <li>
 Identify, initiate and implement at least one process improvement and/or innovation annually.
 </li>
 <li>
 Maintain detailed log of plans that are currently being coded and in the process of being loaded.
 </li>
 <li>
 Send confirmations to internal stakeholders when applicable plans have been loaded. Work with programmers to test claims and related system programs to verify impact within the Health Care Processing System (HCPS).
 
 
 </li>
 </ul>
 
 Other
 
 
 
 <ul>
 <li>
 Utilize all capabilities to satisfy one mission &mdash; to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
 </li>
 <li>
 All other duties as assigned.
 
 
 </li>
 </ul>
 
 PHYSICAL DEMANDS/WORK ENVIRONMENT
 
 
 
 The physical demands and work environment described here represent those that an employee must meet to perform this job&rsquo;s essential functions successfully. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.
</div>

Performant Financial Corporation

<div>ABOUT MACHINIFY:
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
ABOUT THE OPPORTUNITY:
Expected Hiring Range: $80-90k
The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditee&rsquo;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<ul><li>
Performs clinical reviews on medical records to maintain subject matter expertise.</li><li>
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.</li><li>
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.</li><li>
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.</li><li>
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.</li><li>
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.</li><li>
May support findings during the appeals process, if needed.</li><li>
May perform primary audit activity as assigned by management.</li><li>
Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction.</li><li>
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.</li><li>
Consults with internal resources as necessary.</li><li>
Become subject matter expert for assigned business segment(s).</li><li>
Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.</li><li>
Participates in and contributes to applicable department meetings.</li><li>
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 policy/procedures training applicable for position.</li><li>
Proactively contributes to continuous improvement of activities and sets positive example.</li><li>
Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.</li><li>
May support training material/tools and best practices development.</li><li>
May identify/make recommendations to management for supplemental team/concept type training.</li><li>
May support training activities for new audit staff or provide supplemental training for existing staff as needed.</li><li>
Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.</li><li>
Receives feedback and adjusts work priority as necessary.</li><li>
Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.</li><li>
Performs job duties with high level of professionalism and maintains confidentiality.</li><li>
Perform other incidental and related duties as required and assigned to meet business needs.</li></ul>
Knowledge, Skills and Abilities Needed<ul><li>
Demonstrated ability to perform claim payment audits with high quality and production results, as well as successful application of skills to conduct quality assurance review of audit work completed by others.</li><li>
Must be able to manage multiple assignments effectively, create documentation outlining findings, Appeals review results and/or documenting suggestions, organize and prioritize workload, problem solve, work independently and with team members.</li><li>
Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary.</li><li>
Strong knowledge of medical documentation requirements and an understanding CMS, Medicaid and/or Commercial insurance programs, particularly the coverage and payment rules and regulations, may be necessary.</li><li>
Experience with utilization management systems or clinical decision-making tools such as Millimen Care Guidelines (MCG) or InterQual.</li><li>
Working knowledge of encoder may be necessary.</li><li>
Reimbursement policy and/or claims software analyst experience may be necessary.</li><li>
Familiarity with interpreting electronic medical records (EHR)</li><li>
Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.</li><li>
Demonstrated ability to consistently apply sound judgment and good effective decision making.</li><li>
Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals.</li><li>
Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions.</li><li>
Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.</li><li>
Demonstrated ability to collaborate effectively in a variety of settings and topics.</li><li>
Excellent editing and proofreading skills.</li><li>
Ability to independently organization, prioritize and plan work activities effectively for self and others; develops realistic action plans with the ability to multi-task effectively.</li><li>
Excellent time management and delivers results balancing multiple priorities.</li><li>
Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.</li><li>
Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.</li><li>
Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.</li><li>
Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.</li><li>
Ability to create documentation outlining findings and/or documenting suggestions.</li><li>
Strong general computer skills, including, but not limited to Desktop and MS Office applications (Intermediate-to-Advanced Excel Skills), application reporting tools, and case management system/tools to review and document findings.</li><li>
Advanced technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.</li><li>
Ability to be flexible and thrive in a high pace environment with changing priorities.</li><li>
Adaptable to applying skills to diverse operational activities to support business needs.</li><li>
Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.</li><li>
Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.</li><li>
Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment.</li></ul>
Required and Preferred Qualifications<ul><li>
Active unrestricted RN license in good standing and diversified nursing experience providing direct care in an inpatient or outpatient setting, is required.</li><li>
At least 5+ years relevant experience in a provider or payer environment demonstrating breadth and depth of auditing knowledge/skills for the position. Less than 5 years may be considered for internal candidates based upon demonstrated skills and results.</li><li>
Not currently sanctioned or excluded from the Medicare program by OIG.</li><li>
Must have strong technical aptitude and intermediate to advanced skills using Excel.</li><li>
One or more years of experience in health care claims that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, bundled payment methodologies and/or medical billing experience for an Insurance Company or hospital or other appropriate medical provider may be required.</li><li>
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions.</li><li>
Prior experience in role with responsibility for conducting primary audit, utilization management or prior-authorization work, or review of audit work performed by others (QA function, appeals function, lead, supervisory role, etc.)</li><li>
Prior experience in payer edit development and/or reimbursement policy a plus.</li><li>
Prior experience working in remote setting is strongly preferred. Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance.</li></ul>
WHAT WE OFFER:
Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
Physical Requirements &amp; Additional Notices:
If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.<ul><li>
Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.</li><li>
Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).</li><li>
Regularly sit/stand 8 or more hours per day.</li><li>
Occasionally lift/carry/push/pull up to 10lbs.</li></ul>
Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:<ul><li>
Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.</li><li>
Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.</li><li>
Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.</li><li>
Other requirements may apply.</li></ul>
All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING</div>

Medical Review Clinical Appeals Auditor (RN)

Machinify

<div>
 
 About Machinify
 
 
 
 In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
 
 
 
 About The Opportunity
 
 
 
 Expected Hiring Range: $72-78k, may be adjusted to reflect applicant experience
 
 
 The
 
 Medical Review Nurse II - Readmissions
 
 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
 
 
 
 <ul>
 <li>
 Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.
 </li>
 <li>
 Document all findings referencing the appropriate policies and rules.
 </li>
 <li>
 Generate letters articulating audit findings.
 </li>
 <li>
 Supporting your findings during the appeals process if requested.
 </li>
 <li>
 Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
 </li>
 <li>
 Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.
 </li>
 <li>
 Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
 </li>
 <li>
 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.
 </li>
 <li>
 Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.
 </li>
 <li>
 Interface with and support the Medical Director and cross train in all clinical departments/areas.
 </li>
 <li>
 Other duties as required to meet business needs.
 
 
 </li>
 </ul>
 
 Knowledge, Skills And Abilities Needed
 
 
 
 <ul>
 <li>
 Knowledge of insurance programs, particularly the coverage and payment rules.
 </li>
 <li>
 Ability to maintain high quality work while meeting strict deadlines.
 </li>
 <li>
 Excellent written and verbal communication skills.
 </li>
 <li>
 Ability to manage multiple tasks including desk audits and claims review.
 </li>
 <li>
 Must be able to independently use standard office computer technology.
 </li>
 <li>
 Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload
 </li>
 <li>
 Effectively work independently and as a team, in a remote setting.
 
 
 </li>
 </ul>
 
 Required And Preferred Qualifications
 
 
 
 <ul>
 <li>
 Active unrestricted RN license in good standing, is required.
 </li>
 <li>
 Must not be currently sanctioned or excluded from the Medicare program by the OIG.
 </li>
 <li>
 Minimum of five (5) years diversified nursing experience providing direct care in an inpatient setting.
 </li>
 <li>
 One (1) or more years' experience performing medical records review.
 </li>
 <li>
 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.
 </li>
 <li>
 Other qualifications may be required and would be discussed during an interview.
 
 
 </li>
 </ul>
 
 What We Offer
 
 
 
 Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
 
 
 
 Physical Requirements &amp; Additional Notices
 
 
 
 
 If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required
 
 . Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
 
 
 The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.
 
 
 <ul>
 <li>
 Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.
 </li>
 <li>
 Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).
 </li>
 <li>
 Regularly sit/stand 8 or more hours per day.
 </li>
 <li>
 Occasionally lift/carry/push/pull up to 10lbs.
 
 
 </li>
 </ul>
 
 Requirements
 
 
 
 Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:
 
 
 <ul>
 <li>
 Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.
 </li>
 <li>
 Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.
 </li>
 <li>
 Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.
 </li>
 <li>
 Other requirements may apply.
 
 
 </li>
 </ul>
 All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
 
 
 Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
 
 
 Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
 
 
 THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING
</div>

Medical Review Nurse - Readmissions

<div>ABOUT MACHINIFY:
In October 2025, Machinify acquired Performant and we are now part of the Machinify organization. Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plans. Deployed by over 75 health plans, including many of the top 20, and representing more than 170 million lives, Machinify&rsquo;s AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We&rsquo;re reshaping healthcare payment through seamless intelligence.
ABOUT THE OPPORTUNITY:
Expected Hiring Range: $84,000 - $100,000 (based on experience)
The Medical Review Nurse II - SNF/MDS 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:<ul><li>
Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules.</li><li>
Document all findings referencing the appropriate policies and rules.</li><li>
Generate letters articulating audit findings.</li><li>
Supporting your findings during the appeals process if requested.</li><li>
Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.</li><li>
Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits.</li><li>
Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.</li><li>
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.</li><li>
Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines.</li><li>
Interface with and support the Medical Director and cross train in all clinical departments/areas.</li><li>
Other duties as required to meet business needs.</li></ul>
Knowledge, Skills and Abilities Needed:<ul><li>
Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.</li><li>
Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.</li><li>
Knowledge of insurance programs program, particularly the coverage and payment rules.</li><li>
Ability to maintain high quality work while meeting strict deadlines.</li><li>
Excellent written and verbal communication skills.</li><li>
Ability to manage multiple tasks including desk audits and claims review.</li><li>
Must be able to independently use standard office computer technology (e.g. email telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.</li><li>
Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload</li><li>
Effectively work independently and as a team, in a remote setting.</li></ul>
Required and Preferred Qualifications:<ul><li>
Active unrestricted RN license in good standing, is required.</li><li>
Must not be currently sanctioned or excluded from the Medicare program by the OIG.</li><li>
Minimum of five (5) years diversified nursing experience providing direct care in an inpatient or outpatient setting.</li><li>
One (1) or more years' experience performing medical records review.</li><li>
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.</li><li>
Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions.</li></ul>
WHAT WE OFFER:
Machinify offers a wide range of benefits to help support a healthy work/life balance. These benefits include medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, as well as paid time off annually. For more information about our benefits package, please refer to our benefits page on our website or discuss with your Talent Acquisition contact during an interview.
Physical Requirements &amp; Additional Notices:
If working in a hybrid or fully remote setting, access to reliable, secure high-speed Internet at your home office location is required. Proof of such may be required prior to an offer being made. It is the Employee&rsquo;s responsibility to maintain this Internet access at their home office location.
The following is a general summary of the physical demands and requirements of an Office/Clerical/Professional or similar job, whether completed remotely at a home office or in a typical on-site professional office environment. This is not intended to be an exhaustive list of requirements, as physical demands of each individual job may vary.<ul><li>
Regularly sits at a desk during scheduled shift, uses office phone or headset provided by the Company for phone calls, making outbound calls and answering inbound return calls using an office phone system; views a computer monitor, types on a keyboard and uses a computer mouse.</li><li>
Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).</li><li>
Regularly sit/stand 8 or more hours per day.</li><li>
Occasionally lift/carry/push/pull up to 10lbs.</li></ul>
Machinify is a government contractor and subject to compliance with client contractual and regulatory requirements, including but not limited to, Drug Free Workplace, background requirements, and other clearances (as applicable). As such, the following requirements will or may apply to this position:<ul><li>
Must submit to, and pass, a pre-hire criminal background check and drug test (applies to all positions). Ability to obtain and maintain client required clearances, as well as pass regular company background and/or drug screenings post-hire, may be required for some positions.</li><li>
Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.</li><li>
Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.</li><li>
Other requirements may apply.</li></ul>
All employees and contractors for Machinify may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times. Violations to Machinify's policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.
Machinify is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Machinify will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if you believe a reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please contact Machinify&rsquo;s Human Resources team to discuss further.
Our diversity makes Machinify unique and strengthens us as an organization to help us better serve our clients. Machinify is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.
THIRD PARTY RECRUITMENT AGENCY SUBMISSIONS ARE NOT ACCEPTED UNLESS EXPLICITY AGREED TO IN WRITING</div>

Medical Review Nurse - SNF/MDS Auditor (Government-CMS RAC))

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Medical Review Nurse - SNF/MDS Auditor (Government-CMS RAC))