RN Nurse Auditor

Medical University of South Carolina • Charleston, SC

115d

About The Position

The RN Nurse Auditor is a key member of the Clinical Appeals team and reports directly to the Clinical Appeals Manager. This role is responsible for conducting clinical reviews of payer audit determinations, identifying improper denials, and preparing detailed appeals that support the validity of charges and medical necessity of services rendered. Utilizing strong clinical judgment, in-depth knowledge of payer policies, and regulatory compliance standards, the RN Nurse Auditor advocates for appropriate reimbursement and contributes to the financial health of the organization. The RN Nurse Auditor also identifies denial trends, conducts root cause analysis, and produces actionable reports to drive continuous improvement across Revenue Cycle operations. The role collaborates with Hospital Patient Accounting, Revenue Integrity, Case Management, Utilization Review, Compliance, and clinical departments to mitigate denial risks, provide education, and ensure clinical documentation supports reimbursement integrity.

Requirements

• Bachelor's degree in Nursing from an accredited school of nursing.
• Minimum of three years related nursing experience.
• Demonstrated knowledge of payer reimbursement for governmental and managed care payers.
• Excellent written and verbal communication skills.
• Licensure as a Registered Nurse by the South Carolina Board of Nursing or compact state.
• Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification.

Responsibilities

• Conduct clinical reviews of payer audit determinations.
• Identify improper denials.
• Prepare detailed appeals supporting the validity of charges and medical necessity of services rendered.
• Utilize strong clinical judgment and knowledge of payer policies.
• Advocate for appropriate reimbursement.
• Contribute to the financial health of the organization.
• Identify denial trends and conduct root cause analysis.
• Produce actionable reports to drive continuous improvement.
• Collaborate with various departments to mitigate denial risks.
• Provide education to ensure clinical documentation supports reimbursement integrity.

What This Job Offers

• Career Level: Mid Level
• Education Level: Bachelor's degree
• Number of Employees: 5,001-10,000 employees