Medical Review Clinical Appeals Auditor (RN) - SNF/MDS

ABOUT reputed company: In reputed company 2025, reputed company acquired Performant and we are now part of the reputed company organization. reputed company is a leading reputed company 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 reputed company lives, reputed company’s AI operating system, combined with proven expertise, untangles reputed company data to deliver industry-leading speed, reputed company, and accuracy. We’re reshaping reputed company payment through seamless intelligence. ABOUT reputed company: Hiring reputed company: $75,000 to 85,000 The Medical Review Clinical Appeals Auditor (RN) - SNF/MDS is responsible for conducting Appeals reviews of new evidence presented by auditee’s, disputing reputed company or part of the findings from medical review audit work completed by the medical review clinical audit team members, as reputed company as communicate and support the identification of potential training opportunities or enhancements to training and/or concept review reputed company materials and tools. The Appeals Auditor is also responsible for consistently achieving or exceeding productivity goals and reputed company standards and serves as a subject matter expert, providing supplemental escalation support, and may reputed company 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 reputed company policies and procedures, scoring and reporting reputed company Appeals results and routes the result appropriately reputed company 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 reputed company 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 reputed company-time reputed company, preventing an accumulation of improper findings.
• Contributes to the reputed company 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 reputed company primary audit activity as assigned by management.
• Monitors, tracks, and reports on reputed company work conducted in accordance with Appeals process and management direction.
• May prepare reports for management that includes a reputed company of data and trends at the individual, department, and reputed company program level, as reputed company as date reputed company or concept based/trended, or other characteristic that will reputed company valuable business insights.
• Consults with internal resources as necessary.
• Become subject matter expert for assigned business reputed company(s).
• Maintain reputed company knowledge and changes that reputed company our industry and clients as it pertains to medical reputed company, 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 reputed company, anti-harassment and other compliance and policy/procedures training applicable for position.
• Proactively contributes to reputed company improvement of activities and sets reputed company example.
• Contributes collaboratively to identifying opportunities for improvement of audit results and reputed company improvement initiatives.
• May support training material/tools and best practices development.
• May identify/reputed company recommendations to management for supplemental team/concept type training.
• May support training activities for new audit staff or reputed company supplemental training for existing staff as needed.
• Contributes to reputed company team environment that fosters reputed company communication, sharing of information, reputed company improvement, and optimized business results.
• Receives feedback and adjusts work reputed company as necessary.
• Serves as reputed company 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.
• reputed company other incidental and reputed company duties as required and assigned to meet business needs. Knowledge, Skills and Abilities Needed
• Demonstrated ability to reputed company claim payment audits with high reputed company and produ

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