performs clinical audit/validation processes to ensure that medical record documentation and diagnosis coding for services rendered is complete, compliant and accurate to support optimal reimbursement
validates and interprets medical documentation to ensure capture of all relevant coding
identifies members with high risk CMS Hierarchical Condition Categories (HCC) and refers cases for annual follow-up care by disease management, case management, and primary care providers as appropriate for assessment/intervention
identifies the root cause analysis of audit findings and submits recommendations for appropriate change management
applies clinical and coding experience to conduct reviews of provider codes and billing
understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas
makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed
follows established guidelines/procedures

Active Registered Nurse (RN) license in the state they reside
Minimum of 2 consecutive years acute inpatient hospital care experience in critical, intensive care setting within the last 5 years (Not pediatrics or neonatal)
In depth knowledge and critical understanding of complex medical diagnoses including, but not limited to, Sepsis, Pneumonia, Acidosis, Renal Failure, Encephalopathy, CVA, DKA, MI, etc.
Advanced knowledge of MS Office (Word, Excel, etc)
Excellent writing, editing, interpersonal, planning, teamwork, and communications skills
Demonstrated ability to exercise solid judgment and discretion in handling and disseminating information
Ability to work independently and manage workload
Customer-service focused and exhibit professionalism, flexibility, dependability, desire to learn, commitment to excellence and commitment to profession
Bachelor’s Degree in relevant field preferred
Inpatient coding certification (AHIMA or AAPC – ex: RHIA, RHIT, CCS, CIS, CIC)
Inpatient coding claim experience
Prospective payment methodologies, DRG auditing experience
Clinical documentation improvement knowledge (CDE, CDEI certification)

medical, dental and vision benefits
401(k) retirement savings plan
time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
short-term and long-term disability
life insurance

Nurse Auditor

Key skills