Job Description

Job Title: Clinical Nurse Auditor – Payment Integrity

We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a Registered Nurse (RN) with coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential, through AAPC or AHIMA Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential.

How You Will Make an Impact

• Investigations and Audits Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
• Tool and Policy Development Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
• Cross-Departmental Collaboration Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
• Data Analysis and Trending Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
• Fraud Detection Support Support fraud investigators with medical review expertise to detect and address fraudulent activities.
• Mentorship Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Requirements

Qualifications

• Education
• Minimum Associate’s Degree in Nursing required;
• Licensure & Certification
• Current, unrestricted Registered Nurse (RN) license in applicable state(s).
• Certification in medical coding from AAPC or AHIMA (e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
• Experience
• Minimum 5 years of clinical nursing experience, preferably with exposure to hospital bill auditing or defense auditing.
• Strong knowledge of provider manuals, reimbursement policies, and medical policy guidelines
• Prior experience with healthcare fraud investigation and auditing is highly preferred.
• Skills
• Proficiency in CPT/HCPCS and ICD-10 coding, with a strong foundation in auditing, accounting, and control principles.
• Analytical and problem-solving skills with a keen attention to detail.
• Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
• Strong proficiency in Microsoft Office and familiarity with audit tracking systems.

Preferred Traits

• Meticulous, organized, and objective in analyzing claims and documentation.
• Ethical and responsible, with a commitment to supporting the integrity of healthcare billing and reimbursement.
• Able to work independently, stay current with rapidly changing healthcare regulations, and thrive in a fast-paced environment.