Nurse Review Auditor (REMOTE)

EnableComp•United States - Remote, TN

6d•Remote

About The Position

EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations, leveraging over 24 years of industry-leading expertise and its unified E360 RCM Position Summary The Clinical Nurse Auditor is responsible for performing comprehensive clinical audits to ensure medical necessity, regulatory compliance, and payer guideline adherence across a broad portfolio of high-complexity claims. This role applies expert clinical judgment to evaluate medical services, admission status, level of care, and coverage determinations for claims involving non-standard benefits, jurisdictional variances, and specialized regulatory frameworks. The Clinical Nurse Auditor partners with internal and external stakeholders to identify trends, mitigate risk, and support accurate reimbursement through accurate documentation and well-supported clinical appeals.

Requirements

Active RN license with ADN or BSN required. Compact State licensure preferred.
Minimum of 2 years’ experience in: Medical Necessity Reviews Admission/Length of Stay LCD/NCD interpretation and application DRG validation and downgrade reviews Line-item reviews
3-5 years’ acute care hospital experience in one of more of the following: ICU/Trauma Surgery Orthopedics Neurosurgery
Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
Elevated level of analytical ability and attention to detail
Excellent written and verbal communication skills
General computer skills (including use of Microsoft Office, specifically Excel and Outlook, internet search).
Strong verbal, written and interpersonal communication skills.
Ability to think critically and make decisions within individual role and responsibility.
Strong organizational and time management skills with the ability to manage workload independently.
Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).
Proven knowledge of trauma/medical/surgical procedures, clinical treatment patterns and healthcare practices and trends
Strong clinical assessment and critical thinking skills.
Familiarity with health care documentation systems.
Ability to interpret policies and procedures and communicate complex topics to others.
Ability to communicate audit outcomes and clinical appeal strategies with other staff within the company who are both medically and non-medically oriented.

Nice To Haves

Professional Coding Credentials: AAPC and/or AHIMA certification (e.g., CPC, CCS, RHIA, RHIT) reflecting advanced understanding of coding standards and regulatory requirements is a plus
Technology Proficiency: Demonstrated familiarity with EMR/EHR systems and the ability to efficiently navigate electronic medical records across multiple platforms
Audience-Adaptive Communication: Ability to clearly articulate audit outcomes, clinical rationale, and recommendations to both medically trained professionals and non-clinical audiences, ensuring understanding, alignment, and actionable next steps

Responsibilities

Review, analyze, and resolve high-complexity claims and denials requiring advanced clinical judgment, payer-specific interpretation, and regulatory expertise.
Determine appropriate admission type, level of care, length of stay, care setting, and coverage based on clinical documentation and payer-specific rules.
Apply appropriate medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG, LCD/NCD, and payer-specific policies).
Perform line-item reviews to validate accuracy, compliance, and reimbursement integrity.
Review DRG assignments and downgrades and identify opportunities for support, correction, or appeal.
Document clear, concise opinions, conclusions, and recommendations supported by clinical evidence.
Compose high-quality clinical appeals with supporting documentation from nationally recognized sources (e.g., CMS, peer-reviewed literature, InterQual/MCG, specialty society guidance, etc.).
Identify trends, risks, and educational opportunities across audit findings.
Communicate results and insights to internal leadership and external partners in a professional and actionable manner.
Support continuous improvement efforts through data-driven recommendations and collaboration with operational teams.
Provide guidance and clinical insight to support alignment, knowledge-sharing, and quality outcomes across global operations.
Collaborate with domestic and international teams to ensure consistency in medical review standards, audit methodology, and best practices.
Communicate audit findings, clinical rationale, and recommendations clearly and professional across a globally distributed workforce.