--- title: 'Medical Review Nurse - CMS/RAC Auditor, Government Audits at Machinify' canonical: 'https://feeny.ai/job/medical-review-nurse-cms-rac-auditor-government-audits-machinify-united-states-ygxgtrhkqdjf' type: 'job' last_seen: '2026-09-16' --- # Medical Review Nurse - CMS/RAC Auditor, Government Audits at Machinify - **Company:** Machinify - **Location:** United States - **Work type:** remote - **Posted:** 2026-08-11 - **Last confirmed live:** 2026-09-16 - **Apply:** https://job-boards.greenhouse.io/machinifyinc/jobs/4363387009 ## Job description Machinify is a leading healthcare intelligence company with expertise across the payment continuum, delivering unmatched value, transparency, and efficiency to health plan clients across the country. Deployed by over 85 health plans, including many of the top 20, and representing more than 270 million lives, Machinify brings together a fully configurable and content-rich, AI-powered platform along with best-in-class expertise. We’re constantly reimagining what’s possible in our industry, creating disruptively simple, powerfully clear ways to maximize financial outcomes and drive down healthcare costs. The Medical Review Nurse - CMS / RAC (Government Audits) primarily performs medical claims audit reviews for government clients. As a MR Nurse, you will join a team of experienced medical auditors and coders performing retrospective and prepayment audits on claims for Government Payers.  You will work remotely in a fast paced and dynamic environment and be part of a multi-location team. Please note: RAC certification is preferred for this role. The selected candidate may need to work toward RAC certification if they do not currently have it. Key Responsibilities: - Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. - Document all findings referencing the appropriate policies and rules. - Generate letters articulating audit findings. - Supporting your findings during the appeals process if requested. - Working collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. - Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. - Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. - 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. - Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. - Interface with and support the Medical Director and cross train in all clinical departments/areas. - Other duties as required to meet business needs. Knowledge, Skills and Abilities Needed: - Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual. - Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding. - Knowledge of insurance programs program, particularly the 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. - 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. - Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload - Effectively work independently and as a team, in a remote setting. Required and Preferred Qualifications: - 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 that demonstrates expertise in, ICD-9/ICD-10 coding, HCPS/CPT coding, DRG and medical billing experience for an Insurance Company or hospital required. - Strong preference for experience performing utilization review for an insurance company, Tricare, MAC, or organizations performing similar functions. - RAC certification preferred. ## Equal Employment Opportunity at Machinify We are committed to 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. We are proud to be an equal opportunity workplace. Machinify is an employment at will employer. We participate in E-Verify as required by applicable law. In accordance with applicable state laws, we do not inquire about salary history during the recruitment process. If you require a reasonable accommodation to complete any part of the application or recruitment process, please let our recruiters know. See our Candidate Privacy Notice at: https://www.machinify.com/candidate-privacy-notice/ ## About Machinify ## Company Overview - **One-liner**: Machinify uses artificial intelligence (AI) to improve healthcare payment integrity, reducing costs and ensuring accurate claims processing for health plans. - **Entity Type**: Private (Acq – Fin stage; investors include New Mountain Capital, Matrix Partners, Battery Ventures, GV) - **Headquarters**: Palo Alto, California, United States - **Founded**: 2015 (per CBInsights) or 2016 (per Built In) - **Founders**: Not publicly available from provided sources ## Core Business - **Primary industry**: Healthcare IT – Payment Integrity & Analytics - **Target customers**: B2B, serving health plans (commercial, Medicare, Medicaid) – 85+ customers including 18 of the top 20 health plans - **Mission/purpose**: “Reshaping healthcare payment through seamless intelligence” – improving performance and affordability for the entire healthcare ecosystem ## Products & Services - **AI Operating System for Payment Integrity**: A platform that includes foundation models trained on billions of healthcare data points, a unified data layer (claims, medical records, contracts, policies), task‑specific intelligent agents, and feedback loops for continuous improvement. - **Payment Integrity Solutions**: Products cover the full spectrum of payment integrity interventions (e.g., DRG review, outpatient audit, subrogation, specialty recovery, claims editing). Deployment models include fully insourced, hybrid, or fully managed. ## Market Standing - **Valuation / Market Cap**: Not disclosed - **Key Metric**: Total funding $10.68M (latest round: Acq – Fin; investors include New Mountain Capital, Matrix Partners, Battery Ventures, GV, Paycheck Protection Program, and others) - **Notable Investors/Partners**: New Mountain Capital, Matrix Partners, Battery Ventures, GV (Google Ventures) - **Growth Signals**: - 85+ customers, including 18 of the top 20 health plans - Covers 270M member lives across commercial, Medicare, and Medicaid - Over $6B in annual cost avoidance and recoveries realized - Currently posting ~48 open roles on Greenhouse (as of search date) ## Competitive Advantages - **AI‑native platform** trained on billions of healthcare data points, combining foundation models, unified data, and task‑specific agents for high‑precision results - **Deep domain expertise** – the team brings 40+ years of combined experience in healthcare payment accuracy - **Flexible deployment** (insourced, hybrid, fully managed) adapts to customer strategy - **Proven scale** (270M member lives, top health plans) demonstrates trust and effectiveness ## Strategic Focus - **Expanding payment integrity interventions** across the full care continuum (commercial, Medicare, Medicaid) - **Continuous improvement** through human‑in‑the‑loop feedback loops - **Investing in AI safety and transparency** while scaling platform capabilities ## Why Work Here - **Culture**: Values-driven (Think Big, Be Humble, Deliver Results, Ask Why, Optimize for Customer Impact); transparent, collaborative environment - **Work model**: Fully remote roles available (US‑based), with some roles requiring onsite presence in Palo Alto, La Grange (KY), or Hendersonville (TN). Hybrid schedules are also supported. - **Technology stack**: Rust, machine learning, large language models, data engineering, cloud processing - **Career opportunities**: Open positions across Engineering (Rust, Frontend, Backend, Fullstack, Platform), Data Science (NLP, Modeling, Agentic Systems), Product Management, Operations, Clinical & Coding Auditors, and more - **Perks**: Mission‑driven work with direct impact on healthcare affordability; strong emphasis on accountability and trust > **Note**: Machinify warns of active hiring scams – legitimate communications always come from official company email addresses and never require payment. ## Sources 1. [machinify.com](https://www.machinify.com/) – Company overview, products, mission 2. [machinify.com/careers](https://www.machinify.com/careers/) – Culture, values, work model 3. [job‑boards.greenhouse.io/machinifyinc](http://job‑boards.greenhouse.io/machinifyinc) – Current job listings (48 roles) 4. [cbinsights.com](https://www.cbinsights.com/company/machinify) – Funding, stage, investors, headquarters, founding year 5. [builtin.com](https://builtin.com/company/machinify) – Office locations, employee count (96), remote/hybrid policy, technology stack ## Other roles at Machinify - [Finance Intern (Onsite: La Grange, KY)](https://feeny.ai/job/finance-intern-onsite-la-grange-ky-machinify-los-angeles-m3cndpw1e2pr) — Los Angeles, CA - [Director, Business Operations & Strategy (Onsite: Dallas, TX)](https://feeny.ai/job/director-business-operations-strategy-onsite-dallas-tx-machinify-dallas-0w7e59xd8rmm) — Dallas, TX - [Medical Review Nurse, Clinical Appeals Auditor](https://feeny.ai/job/medical-review-nurse-clinical-appeals-auditor-machinify-united-states-kjk8kb50wgxv) — United States - [Coding Validation Specialist (Behavioral Health / Substance Use Disorder)](https://feeny.ai/job/coding-validation-specialist-behavioral-health-substance-use-disorder-machinify-d4eh57a2t09w) — United States - [Senior Software Engineer, Backend | Audit Product Team](https://feeny.ai/job/senior-software-engineer-backend-audit-product-team-machinify-united-states-pb394bhcmzz7) — United States - [Manager, Complex Clinical Review](https://feeny.ai/job/manager-complex-clinical-review-machinify-united-states-4f440xe62hjh) — United States - [Manager, Itemized Bill Review (Healthcare)](https://feeny.ai/job/manager-itemized-bill-review-healthcare-machinify-united-states-b18ppqhg5fg7) — United States - [Pharmacy Team Attorney](https://feeny.ai/job/pharmacy-team-attorney-machinify-los-angeles-fs5ddzvzshb8) — Los Angeles, CA - [DME Supervisor](https://feeny.ai/job/dme-supervisor-machinify-united-states-gsh1k6fbqfnz) — United States - [Training Specialist, Medical Review Audit – Clinical RN](https://feeny.ai/job/training-specialist-medical-review-audit-clinical-rn-machinify-united-states-4314twdk0gtf) — United States