RN Nurse Auditor
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 and a minimum of three years related nursing experience required.
- Demonstrated knowledge of payer reimbursement for both governmental and managed care payers required.
- Excellent written and verbal communication skills necessary.
- Licensure as a Registered Nurse by the South Carolina Board of Nursing or compact state required.
- Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.
- Ability to perform job functions while standing. (Continuous)
- Ability to perform job functions while sitting. (Continuous)
- Ability to perform job functions while walking. (Continuous)
- Ability to bend at the waist. (Continuous)
- Ability to perform gross motor activities with fingers and hands. (Continuous)
- Ability to perform firm grasping with fingers and hands. (Continuous)
- Ability to perform fine manipulation with fingers and hands. (Continuous)
- Ability to perform repetitive motions with hands/wrists/elbows and shoulders. (Continuous)
- Ability to fully use both legs. (Continuous)
- Ability to reach in all directions. (Continuous)
- Ability to maintain 20/40 vision, corrected, in one eye or with both eyes. (Continuous)
- Ability to see and recognize objects close at hand or at a distance. (Continuous)
- Ability to match or discriminate between colors. (Continuous)
- Ability to determine distance/relationship between objects; depth perception. (Continuous)
- Good peripheral vision capabilities. (Continuous)
- Ability to maintain hearing acuity, with correction. (Continuous)
- Ability to perform gross motor functions with frequent fine motor movements. (Continuous)
- Ability to deal effectively with stressful situations. (Continuous)
- Ability to work in a latex safe environment. (Continuous)
- Ability to maintain tactile sensory functions. (Continuous)
Responsibilities
- Conducting clinical reviews of payer audit determinations
- Identifying improper denials
- Preparing detailed appeals that support the validity of charges and medical necessity of services rendered
- Advocating for appropriate reimbursement
- Identifying denial trends
- Conducting root cause analysis
- Producing actionable reports to drive continuous improvement across Revenue Cycle operations
- Collaborating 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.
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What This Job Offers
Job Type
Full-time
Number of Employees
5,001-10,000 employees
