Clinical Documentation & Utilization Nurse Auditor

Cano Health • Miami, FL

2d

About The Position

It's rewarding to be on a team of people that truly believe in making an impact! We are committed to building the best primary care environment for patients and are seeking healthcare enthusiasts to join us. Job Summary The Clinical Documentation & Utilization NurseAuditor is responsible for conducting comprehensive clinical audits to evaluate the accuracy, quality, and compliance of patient care documentation, utilization practices, and adherence to evidence-based clinical pathways. This role focuses heavily on chronic condition management (including COPD, Heart Failure, Diabetes, Metabolic syndrome, and Dementia) and compliance with CMS regulations, particularly Annual Wellness Visit (AWV) requirements. The Nurse Clinical Auditor works independently while collaborating with interdisciplinary clinical, care management, and leadership teams to identify care gaps, ensure regulatory compliance, and support quality improvement initiatives that enhance patient outcomes and organizational performance.

Requirements

• Active Registered Nurse (RN) license required
• Minimum of 5 years of clinical nursing experience, preferably in acute care, chronic care, or population health settings
• At least 2 years of experience in utilization management, case management, clinical auditing, or quality assurance
• Demonstrated experience managing or auditing care for chronic conditions such as COPD, CHF, Diabetes, and Dementia
• Contributes to moderately complex projects with a high degree of independence.
• Works collaboratively across clinical and operational teams.
• Strong knowledge of CMS regulations, AWV requirements, and clinical documentation standards
• Proficiency in utilization management and quality audit processes
• Experience with clinical documentation and EMR systems (e.g., eClinicalWorks or similar)
• Understanding of medical coding principles and payer authorization processes
• Excellent analytical, communication, and report-writing skills
• Ability to work independently while collaborating effectively with interdisciplinary teams
• Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing.

Nice To Haves

• Bachelor’s degree in Nursing (BSN) preferred

Responsibilities

• Clinical Documentation & Quality Auditing Conduct detailed audits of patient charts and clinical documentation to ensure accuracy, completeness, and compliance with CMS guidelines and organizational standards.
• Validate documentation related to chronic condition management plans, interventions, and outcomes.
• Support Clinical Documentation Improvement (CDI) initiatives to enhance care quality and audit readiness.
• Clinical Pathway & Care Management Evaluation Assess adherence to evidence-based clinical pathways for COPD, Heart Failure , Diabetes,Metabolic Syndrome and Dementia.
• Identify deviations from established standards of care and provide actionable feedback to improve care consistency and outcomes.
• Monitor patient charts concurrently during treatment to evaluate appropriateness of care delivery.
• Annual Wellness Visit (AWV) Compliance Review and audit Annual Wellness Visits to ensure proper application of CMS guidelines, including preventive screenings, risk assessments, and required documentation elements.
• Ensure accurate coding and documentation for all AWV components to support compliance and reimbursement.
• Utilization Management & Resource Optimization Conduct utilization reviews to determine whether patients are receiving care appropriate to their illness or condition.
• Analyze utilization patterns to identify overutilization or underutilization of services.
• Review treatment plans, authorization status, and insurer approvals to ensure appropriate and cost-effective resource use.
• Consult with physicians and care teams as needed to clarify clinical decisions and documentation.
• Quality Improvement & Reporting Prepare detailed audit reports outlining findings, trends, risks, and actionable recommendations.
• Collect, compile, and report data in accordance with internal policies and regulatory requirements.
• Participate in quality assurance, quality improvement, and staff education initiatives.
• Contribute insights and findings to senior and executive leadership as needed.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 1,001-5,000 employees