Clinical Quality Assurance Nurse Auditor (32604)

ExamWorks•Redding, CA

13d•$34 - $35•Remote

About The Position

This is a high-impact role where your sharp clinical eye directly protects patients, providers, and healthcare standards. As our Clinical Quality Assurance Nurse Auditor, you will be the final line of defense for medical accuracy and compliance. Your expertise ensures that clinical reports, medical record chronologies, and billing reviews are bulletproof, evidence-based, and of the highest professional standard. You will champion report excellence, uphold evidence-based medicine, act as a strategic partner with reviewing physicians, guard compliance and integrity, and proactively solve problems related to client quality questions and missing medical data.

Requirements

Active Registered Nurse (RN) license
Strong clinical judgment
Exceptional proofreading, auditing, and analytical skills
Deep understanding of medical coding, hospital billing, and record chronologies
Familiarity with state and federal healthcare mandates (like ERISA) is a massive plus
Ability to give constructive feedback to medical peers and providers with professionalism and clarity
Bachelor/Associate degree in nursing or related field; or minimum five years related experience; or equivalent combination of education and experience.
Experience with medical terminology, medications, medical specialties and treatment protocols required.
RN/LPN license

Nice To Haves

ICU experience
Experience in the insurance industry preferred

Responsibilities

Review and refine critical medical reports, chronologies, and provider bills to ensure flawless clinical accuracy and professional presentation.
Verify that every clinical determination is backed by robust, current citations from reputable medical journals.
Collaborate directly with reviewing physicians to clarify complex case details and resolve inconsistencies.
Ensure full alignment with federal ERISA regulations, state mandates, and client specifications, while strictly verifying that no conflicts of interest exist.
Help resolve client quality questions, recover missing medical data, and provide management with strategic insights on consultant performance.
Evaluate clinical information received, write and/or review various reports including, but not limited to, Medical Record Reviews, Medical Record Chronologies, Provider Bill Reviews, Coding Reviews, Hospital Bill Reviews, List of Missing Records, Medical Bill Apportionments, Mock Billing Invoice and Medical Summary Statements.
Perform quality assurance review of peer review reports, correspondences, addendums or supplemental reviews.
Ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
Ensure that all client instructions and specifications have been followed and that all questions have been addressed.
Ensure each review is supported by clinical citations and references when applicable and verify that all references cited are current and obtained from reputable medical journals and/or publications.
Ensure the content, format, and professional appearance of the reports are of the highest quality and in compliance with company standards.
Ensure the appropriate board specialty has reviewed the case in compliance with client specifications and/or state mandates and is documented accurately on the case report.
Verify that the reviewer has attested to only the facts and that no evidence of reviewer conflict of interest exists.
Ensure the provider credentials and signature are adhered to the final report.
Identify any inconsistencies within the report and contacts the Reviewer to obtain clarification, modification or correction as needed.
Contact the appropriate person to recover any missing documentation or verify charges.
Assist in resolution of customer complaints and quality assurance issues as needed.
Ensure all federal ERISA or state mandates are adhered to at all times.
Provide insight and direction to management on consultant quality, availability and compliance with all company policies and procedures and client specifications.
Promote effective and efficient utilization of company resources.
Participate in various continuing education requirements and or training activities.
Perform other duties as assigned.