The Medical Review Audit Supervisor is a working supervisor who leads a remote team of clinical auditors performing medical record review, with primary oversight of Skilled Nursing Facility (SNF) audits. This role requires a licensed nurse with SNF clinical and/or reimbursement experience, command of Medicare Part A SNF coverage rules, the Patient Driven Payment Model (PDPM), and MDS 3.0 documentation, and the leadership presence to drive performance, hold the team accountable, and develop staff.
Team Leadership & Performance Management
- Directly supervise a team of clinical auditors and audit associates; set clear productivity and quality expectations and hold the team to them consistently.
- Conduct regular performance reviews, coaching conversations, and constructive feedback sessions; escalate performance concerns through appropriate Leader and/or HR channels.
- Lead regular team meetings to align priorities, communicate updates, and maintain engagement in a remote environment.
- Monitor and manage time, attendance, and scheduling in accordance with company policy.
- Identify training gaps and coordinate targeted development, including calibration on PDPM classification, skilled need, and level of care determinations; support onboarding of new audit staff.
SNF Audit Oversight & Quality
- Serve as the primary subject matter authority for SNF audit programs; maintain current, working knowledge of Medicare Benefit Policy Manual Chapter 8 coverage requirements, PDPM, the MDS 3.0 RAI Manual, SNF consolidated billing, and Medicare Advantage and commercial SNF reimbursement policy.
- Maintain personal audit proficiency by performing a limited volume of SNF claim reviews; serve as technical resource and escalation point for complex or disputed cases, including skilled need, level of care, and PDPM component disputes.
- Oversee audit determinations on qualifying hospital stays, physician certification and recertification, daily skilled services, and MDS coding accuracy to ensure findings are consistent, defensible, and grounded in the medical record.
- Collaborate with the QA team to translate audit findings and error trends into clear, actionable feedback for auditors, driving continuous improvement in audit accuracy.
- Monitor team inventory and workflow to proactively identify and address backlogs before they impact SLAs.
- Use production and quality data to identify trends, surface opportunities, and present actionable recommendations to leadership.
- Support implementation of new audit concepts, client requirements, and payer-specific SNF guidelines, including changes from the annual CMS SNF PPS final rule.
Cross-Functional & Strategic Contribution
- Provide reporting and operational updates to management on team activity, performance metrics, and emerging issues.
- Collaborate with QA, Appeals, and segment specialists to resolve operational problems and support continuous improvement.
- Maintain current knowledge of SNF PPS rule changes, MDS item set and RAI Manual updates, and CMS program integrity activity affecting SNF claims.
- Participate in client-facing meetings and support provider training activities.
- Support management in capacity planning, needs assessments, and inventory activity for third-party subcontractors as needed.
Knowledge, Skills, and Abilities
- Deep working knowledge of SNF Part A documentation and coverage requirements, including the 3-day qualifying inpatient stay, physician certification and recertification, daily skilled nursing and therapy needs, and the distinction between skilled and custodial care.
- Command of PDPM case-mix classification, including the PT, OT, SLP, nursing, and NTA components, primary diagnosis clinical category mapping, Section GG functional scoring, and the interrupted stay policy.
- Proficiency in MDS 3.0 coding and RAI Manual guidance, including assessment scheduling, look-back periods, and supporting documentation; ability to validate HIPPS codes against the medical record.
- Strong understanding of CMS, Medicaid, Medicare Advantage, and commercial payer coverage and payment rules for post-acute care, including SNF level of care criteria.
- Proficiency with ICD-10-CM and HCPCS/HIPPS; familiarity with UB-04 institutional claims, SNF bill types, revenue codes, and consolidated billing edits.
- Experience interpreting EHRs, including SNF platforms such as Point Click Care (PCC) or MatrixCare, and applying clinical documentation standards to audit determinations.
- Ability to read, analyze, and clearly communicate complex clinical and billing findings, verbally and in writing, at all organizational levels.
- Strong data analysis skills; able to synthesize production and quality metrics into operational insights.
- Demonstrated track record of leading teams to performance outcomes, not just managing tasks.
- Comfortable operating with ambiguity; identifies problems and drives to resolution without waiting to be directed.
- Proficient in Microsoft Office Suite (intermediate Excel required); experience with case management or audit platforms preferred.
Required Qualifications
- Active, unrestricted nursing license in good standing; not sanctioned or excluded from Medicare by OIG.
- 3+ years of direct patient care experience, including skilled nursing or post-acute care.
- 2+ years performing medical record audits, MDS review, or clinical reimbursement review in a payer, provider, or SNF setting, with direct experience in SNF Part A claims.
- 3+ years of supervisory or team leadership experience in a comparable production environment, or demonstrated readiness for people leadership through activities such as training, mentorship, subject matter expert, or equivalent; experience managing or supporting remote staff strongly preferred
Preferred Qualifications
- Resident Assessment Coordinator Certified (RAC-CT or RAC-CTA) through AAPACN.
- Medical coding certification (CPC, CCS, or equivalent).
- Prior experience as an MDS Coordinator, Director of Nursing, or Director of Clinical Reimbursement in a SNF.
- Experience with Medicare Advantage SNF prior authorization or concurrent review.
- Familiarity with SNF appeals workflows, including MAC redeterminations, and payer-provider dispute resolution processes.
- 5+ years of healthcare claims, coding, or clinical reimbursement experience with demonstrated expertise in ICD-10, PDPM, and MDS coding; SNF billing or MDS coordination experience required.