Job Description:

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

Requirements:

• Minimum

Associate’s Degree in Nursing

required;

• 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.

• 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.

• 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.

Benefits: