Medical Review Nurse - Government/Clinical Outpatient

About Machinify

Machinify, following its acquisition of Performant in October 2025, stands as a leading healthcare intelligence company. We leverage expertise across the payment continuum to deliver unmatched value, transparency, and efficiency to health plans. Our AI operating system, deployed by over 75 health plans and serving more than 170 million lives, combined with proven expertise, untangles healthcare data for industry-leading speed, quality, and accuracy. We are committed to reshaping healthcare payment through seamless intelligence.

About The Opportunity

The Medical Review Nurse - Government/Clinical Outpatient primarily conducts medical claims audit reviews. Joining a team of experienced medical auditors and coders, you will perform retrospective and prepayment audits on claims for Government and Commercial Payers. This is a remote position within a fast-paced, dynamic, and multi-location team environment.

Hiring Range: $75,000 - $80,000

Key Responsibilities

• Audit claims for medically appropriate services in both inpatient and outpatient settings, adhering to medical review guidelines, policies, and rules.
• Document all findings with precise references to appropriate policies and rules.
• Generate comprehensive letters articulating audit findings.
• Support audit findings during the appeals process as needed.
• Collaborate with the audit team to identify and gain approval for particular vulnerabilities and potential abuse cases.
• Partner with clients, CMD colleagues, and other contractors to enhance medical policies, provider education, and system edits.
• Stay informed on medical practice advancements, technological changes, and regulatory issues impacting clients.
• Work with the team to minimize appeals; suggest workflow improvements; assist with QA functions and team training.
• Participate in establishing edit parameters, new issue packets, and developing Medical Review Guidelines.
• Interface with and support the Medical Director; cross-train in all clinical departments/areas.
• Perform other duties as required to meet business needs.

Knowledge, Skills And Abilities Needed

• Experience with utilization management systems or clinical decision-making tools (e.g., Medical Coverage Guidelines (MCG) or InterQual).
• Deep knowledge of ICD-9, ICD-10, CPT-4, or HCPCS coding.
• Understanding of insurance programs, particularly coverage and payment rules.
• Ability to maintain high-quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Proficiency in managing multiple tasks, including desk audits and claims review.
• Ability to independently use standard office computer technology (email, telephone, copier) and case management systems/tools for review and documentation.
• Capability to effectively manage multiple assignments, create detailed documentation, and prioritize workload.
• Proven ability to work independently and collaboratively in a remote setting.

Required And Preferred Qualifications

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

What We Offer

Machinify provides a comprehensive benefits package designed to support a healthy work/life balance, including medical, dental, vision, HSA/FSA options, life insurance coverage, 401(k) savings plans, family/parental leave, paid holidays, and annual paid time off. Further details on benefits are available on our website or through your Talent Acquisition contact.

Key skills/competency

• Medical Claims Audit
• Retrospective Audits
• Prepayment Audits
• Medical Review Guidelines
• ICD-10 Coding
• CPT-4 Coding
• HCPCS Coding
• Utilization Management
• Appeals Process
• Regulatory Compliance