Nurse Auditor Jobs

About The Position

Requirements

• Active, unrestricted Registered Nurse (RN) license issued by the applicable Board of Nursing or licensing authority in the candidate’s state of residence.
• At least 5 years of direct clinical nursing experience in an Intensive Care Unit (ICU) or Critical Care Unit (CCU).
• Strong clinical assessment, critical-thinking, and analytical skills, including the ability to evaluate complex medical records and make independent, evidence-based determinations.
• Solid understanding of acute care clinical practices, disease processes, treatment protocols, and healthcare documentation standards.
• Excellent written communication skills, including the ability to develop clear, well-reasoned clinical narratives with accurate grammar, spelling, punctuation, and supporting rationale.
• Proficiency with Microsoft Office applications, including Outlook, Word, and Excel; Windows-based operating systems; and electronic documentation tools.
• Strong organizational and time-management skills, including the ability to manage multiple audit assignments, adapt to changing priorities, and meet deadlines.
• Ability to work independently in a remote environment while maintaining effective communication, accountability, and collaboration with clinical and operational teams.
• Availability to work Eastern Time Zone hours and willingness to travel up to 25% as needed for training, onsite reviews, or other business requirements.

Responsibilities

• Conduct inpatient and outpatient clinical audits evaluating medical necessity, reasonable and necessary services, prior authorization compliance, clinical validation, and medical service charges.
• Analyze medical records, clinical documentation, and provider information to identify potential improper payments and determine whether billed services meet applicable clinical and regulatory requirements.
• Apply clinical screening criteria, evidence-based guidelines, client-specific requirements, and applicable regulations to make independent, accurate, and well-supported audit decisions.
• Document findings and supporting evidence in ProperPay, developing clear, concise, and clinically sound audit rationales in accordance with procedures and client expectations.
• Collaborate with the DRG Validation Team to identify and document coding and clinical validation issues, ensuring alignment between medical documentation and billed services.
• Escalate complex clinical cases to Physician Advisors when required, following referral procedures and contractual guidelines.
• Meet established audit quality, accuracy, productivity, turnaround-time, and documentation requirements.
• Participate in clinical education, inter-rater reliability assessments, quality reviews, and performance improvement initiatives.
• Partner with Clinical Audit Team Leaders to address audit challenges, communicate operational needs, and adapt to changing client requirements and business priorities.

Benefits

• Competitive compensation
• Comprehensive insurance options
• Matching contributions through the 401(k) plan and share purchase plan
• Paid time off for vacation, holidays, and sick time
• Paid parental leave
• Learning opportunities and tuition assistance
• Wellness and well-being programs