Medical Review Clinical Appeals Auditor (RN)

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's AI operating system, combined with proven expertise, untangles healthcare data to deliver industry-leading speed, quality, and accuracy. We're reshaping healthcare payment through seamless intelligence.

ABOUT THE OPPORTUNITY:

The Medical Review Clinical Appeals Auditor (RN) is responsible for conducting Appeals reviews of new evidence presented by auditee'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

• Performs clinical reviews on medical records to maintain subject matter expertise.

• 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.

• 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.

• 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.

• 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.

• 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.

• May support findings during the appeals process, if needed.

• May perform primary audit activity as assigned by management.

• Monitors, tracks, and reports on all work conducted in accordance with Appeals process and management direction.

• 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.

• Consults with internal resources as necessary.

• Become subject matter expert for assigned business segment(s).

• Maintain current knowledge and changes that affect our industry and clients as it pertains to medical practice, technology, regulations, legislation, and business trends.

• Participates in and contributes to applicable department meetings.

• 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.

• Proactively contributes to continuous improvement of activities and sets positive example.

• Contributes collaboratively to identifying opportunities for improvement of audit results and continuous improvement initiatives.

• May support training material/tools and best practices development.

• May identify/make recommendations to management for supplemental team/concept type training.

• May support training activities for new audit staff or provide supplemental training for existing staff as needed.

• Contributes to positive team environment that fosters open communication, sharing of information, continuous improvement, and optimized business results.

• Receives feedback and adjusts work priority as necessary.

• Serves as positive role model and example for other audit staff and conducts work in accordance with company policies, government regulations and law.

• Performs job duties with high level of professionalism and maintains confidentiality.

• Perform other incidental and related duties as required and assigned to meet business needs.

Knowledge, Skills and Abilities Needed

• 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.

• 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.

• Experience with CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding may be necessary.

• 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.

• Experience with utilization management systems or clinical decision-making tools such as Millimen Care Guidelines (MCG) or InterQual.

• Working knowledge of encoder may be necessary.

• Reimbursement policy and/or claims software analyst experience may be necessary.

• Familiarity with interpreting electronic medical records (EHR)

• Basic understanding of accounting principles for accounts payable and receivable as it relates to medical billing.

• Demonstrated ability to consistently apply sound judgment and good effective decision making.

• Understands Medical Review Audit and Quality Assurance objectives, activities, and key drivers in achieving operational goals.

• Ability to efficiently and effectively run reports, analyze information, identify meaningful trends, and identify potential solutions.

• Strong communication skills, both verbal and written; ability to communicate effectively and professionally at all levels within the organization, both internal external.

• Demonstrated ability to collaborate effectively in a variety of settings and topics.

• Excellent editing and proofreading skills.

• 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.

• Excellent time management and delivers results balancing multiple priorities.

• Strong analytical skills; synthesizes complex or diverse information; collects and researches data; uses experience to compliment data.

• Leverages strong critical thinking, questioning, and listening skills to research and effectively resolve complex issues.

• Demonstrated ability to identify areas of opportunity and create efficiencies in workflows and procedures.

• Demonstrated ability to be proactive; identifies and resolves problems in a timely manner; develops alternative solutions.

• Ability to create documentation outlining findings and/or documenting suggestions.

• 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.

• Advanced technical aptitude with demonstrated ability to quickly learn and adapt to new systems and tools.

• Ability to be flexible and thrive in a high pace environment with changing priorities.

• Adaptable to applying skills to diverse operational activities to support business needs.

• Self-starter with the ability to work independently in remote setting with minimum supervision and direction in the form of objectives.

• Serves as a positive role model; and demonstrates characteristics that align and contribute to a collaborative culture of continuous improvement and high performing teams.

• Capability of working in a fast-paced environment, flexibility with assignments and the ability to adapt in a changing environment.

Required and Preferred Qualifications

• Active unrestricted RN license in good standing and diversified nursing experience providing direct care in an inpatient or outpatient setting, is required.

• 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.

• Not currently sanctioned or excluded from the Medicare program by OIG.

• Must have strong technical aptitude and intermediate to advanced skills using Excel.

• 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.

• Strong preference for experience performing utilization review for an insurance company, Tricare, MAC or organizations performing similar functions.

• 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.)

• Prior experience in payer edit development and/or reimbursement policy a plus.

• Prior experience working in remote setting is strongly preferred. Must be comfortable solving minor/intermediate technical issues, with or without immediate remote assistance.

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 & 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'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.

• 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.

• Regularly reads and comprehends information in electronic (computer) or paper form (written/printed).

• Regularly sit/stand 8 or more hours per day.

• Occasionally lift/carry/push/pull up to 10lbs.

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:

• 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.

• Some positions may require the total absence of felony and/or misdemeanor convictions. Must not appear on any state/federal debarment or exclusion lists.

• Must complete the Machinify Teleworker Agreement upon hire and adhere to the Agreement and all related policies and procedures.

• Other requirements may apply.

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'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