Senior Medical Audit Specialist RN

State of Oklahoma•Oklahoma City, OK

4d•Onsite

About The Position

The Senior Medical Audit Specialist provides clinical expertise in investigations and comprehensive clinical audits to combat fraud, waste, and abuse. The role analyzes billed services, claims, and supporting documentation to determine whether services are clinically and medically appropriate and comply with OHCA policies, state statutes, and federal regulations. The specialist collaborates with teams across the organization and external entities to evaluate audit results, make referrals, and communicate findings to stakeholders. The position also represents the Provider Audits Unit before an Administrative Law Judge and in legal proceedings concerning general provider appeals. The position does not supervise. Work is performed at the Oklahoma Health Care Authority office in Oklahoma City; being present at the office is an essential function, and job-related travel is required. The schedule is Monday through Friday, with primary hours of 8:00 a.m. to 5:00 p.m.

Requirements

Hold a valid permanent Oklahoma Registered Nurse license approved by the Oklahoma Board of Nursing or a Registered Nurse license recognized by the Enhanced Nurse Licensure Compact (eNLC). There is no substitution for licensure.
Have five years of professional experience as a registered nurse.
Include a resume or CV with complete work and education history in the application.
Maintain the required licensure and certifications.
Be willing to complete all job-related travel; presence at the office is an essential function.

Nice To Haves

Certification as a Certified Professional Medical Auditor (CPMA) or Certified Professional Coder (CPC).
General understanding of coding principles, including CPT, HCPCS, ICD-10, and/or DRG.
Experience with Medicaid and Medicare billing audits.
Experience in medical review, auditing, utilization review, compliance, or regulatory work.

Responsibilities

Provide clinical expertise in investigations and comprehensive clinical audits to combat fraud, waste, and abuse.
Ensure billing compliance with OHCA policy, state statutes, and federal regulations.
Analyze and evaluate billed services, claims, and documentation for compliance with HCA policy and clinical or medical appropriateness.
Collaborate with internal teams and external entities to evaluate audit results and make referrals to appropriate parties.
Communicate audit findings to stakeholders.
Represent the Provider Audits Unit before an Administrative Law Judge and in legal proceedings regarding general provider appeals.
Maintain licensure and certifications.
Perform other duties as assigned.