Perform complete government (MAC, CERT, RAC, OIG, ZPIC, UPIC, QIO, TPE, DRG), state (Medicaid, PERM) and commercial (Managed Medicare, Charge/Defense, Level of Care, Medical Necessity, Readmission) payer clinical audit reviews
Assist with analyzing and reviewing clinical audit and DRG clinical validation audits to prevent future audits
Contact regulatory bodies to determine the reason for the audit
Review audit letters, analyzing claims, reviewing for compliance rules and regulations
Gather appropriate medical records from client EMR per government requirements
Prepare the audit materials
Work in tandem with Ensemble/Client compliance educate other departments on any audit outcomes
Assist in developing action plans for prevention
Ensure the delivery of high-quality, cost-effective reviews and minimize financial risk to Ensemble Health Partners and clients.

2+ years of regulatory audit experience, utilization review, clinical validation, denials or case management experience strongly preferred
Experience in hospital operations, chart audit/review, and clinical education
Ability to manage time, meet audit deadlines, and handle multiple tasks
Experience working in a production-based work environment
Flexibility to adapt to changing regulations, work multiple assigned audit tasks and healthcare environments
Ability to work independently and manage workload
Ability to evaluate complex situations and make informed decisions
Familiarity with electronic medical records (EMR) systems
Experience using multiple software programs and tools
Must be inquisitive and demonstrate openness to innovation including AI to explore better processes and ways to alleviate friction and improve patient and client experiences.

RN Clinical Auditor

Key skills