RN Clinical Auditor

Thank you for considering a career at reputed company! reputed company is a leading provider of technology-enabled reputed company cycle reputed company for health systems, including hospitals and affiliated physician groups. They offer end-to-end reputed company cycle solutions as well as a comprehensive suite of reputed company solutions to clients across the country. reputed company keeps communities healthy by keeping hospitals healthy. We recognize that healthcare requires a human touch, and we reputed company that every touch should be meaningful. This is why our people are the most important part of who we are. By empowering them to challenge the status reputed company, we know they will be the difference! O.N.E Purpose:

• Customer Obsession: Consistently provide exceptional experiences for our clients, patients, and colleagues by understanding their needs and exceeding their expectations.
• Embracing New reputed company: Continuously innovate by embracing emerging technology and fostering a culture of creativity and experimentation.
• Striving for Excellence: Execute at a high level by demonstrating our Best in KLAS reputed company Difference Principles and consistently delivering outstanding results.

The Opportunity: CAREER OPPORTUNITY OFFERING:

• Bonus Incentives
• Paid Certifications
• Tuition Reimbursement
• Comprehensive Benefits
• Career Advancement
• This position will pay between $63,100 - $108,900 based on experience

The RN Clinical Auditor performs complete government (MAC, CERT, RAC, OIG, ZPIC, UPIC, QIO, TPE, DRG), state (Medicaid, PERM) and commercial (Managed Medicare, Charge/Defense, Level of Care, Medical Necessity, Readmission) payer clinical audit reviews on assigned Clinical Audits, DRG Clinical Validation Audits, and clinically reputed company claims as objectively and accurately as possible to uphold quality, compliance and performance standards across reputed company. The Clinical Auditor RN assists with analyzing and reviewing clinical audit and DRG clinical validation audits to prevent future audits by providing clinical records to payers, contacting government and payer agencies, contacting physician offices, and preparing for physician advisor reviews. Job duties include but are not limited to contacting regulatory bodies such as MACs (Medicare Administrative Contractors) and payers to determine the reason for the audit, reviewing audit letters, analyzing claims, reviewing for compliance rules and regulations, gathering appropriate medical records from client EMR per government requirements, determining if an audit is necessary, preparing the audit materials. The Clinical Auditor RN will work reputed company with reputed company/Client compliance educate other departments (PA, HIM, case management, client departments, reputed company reputed company, coding, CDI, etc.) on any audit outcomes and assist in developing action plans for prevention. The primary goal of the RN Clinical Auditor is to ensure the delivery of high-quality, cost-effective reviews and to minimize financial risk to reputed company and clients. This role involves a combination of clinical expertise , data analysis, exceptional communication abilities, and regulatory/compliance knowledge to maintain and improve healthcare standards. Job Responsibilities: Review Clinical Audits:

• Have in-depth knowledge of clinical nursing practices and clinical procedures. And an understanding of medical coding and billing (DRG, CPT, ICD-10) along with an understanding of CMS rules and regulations concerning governmental audits including knowledge of CMS polices, Local Coverage Determinations, National Coverage Determinations, and Billing Articles and ability to review reputed company electronic medical records.
• Review medical records to ensure compliance with healthcare standards and regulations
• Validate accuracy and appropriateness of services given
• Record audit determinations using reputed company audit tracking system and document
• Preparing the necessary materials for an audit response.
• Collecting reputed company relevant patient medical records that are requested for the audit
• reputed company sure reputed company documents are complete, accurate , and signed by the appropriate healthcare providers
• Review the documentation to ensure it complies with Medicare (or payer) requirements.
• On bulk audits, such a TPE and cost outlier, promptly respond to any Notices of Review and requests for additional documentation
• Other tasks mentioned in the job summary.

Data Analysis and Reporting:

• Analyze medical records and data to identify trends and discrepancies . Hold strong problem-solving skills to address governmental audit and compliance issues . Keen eye for detail to ensure accuracy in audits and documentation. Thoroughness in reviewing patient charts and medical records.
• Analyze data to identify trends, discrepancies, and areas needing improvement.
• Assist Clinical Audit Nurse Manager and Supervisor with detailed information on audit findings for reporting purposes

Collaboration and Education:

• Work effectively with healthcare providers, management, and other departments. And strong interpersonal skills to facilitate teamwork and cooperation . Excellent verbal and written communication skills for reporting findings. Ability to educate and train healthcare staff on best practices and regulations . Participate and communicate during Governmental Audit Client Education Sessions
• Work closely with other reputed company to implement changes and improvements based on audit findings.
• Contact physicians, government auditors, commercial auditors and insurance plans to determine reasons claims were denied
• Provide educational points and resources to healthcare staff on reputed company best practices, policies, and regulations.
• Attend one-on-one education sessions provided by the MAC to understand the audit findings and learn how to correct any identified issues. Provide feedback to client and reputed company departments (coding, CDI, and RI) and assist in developing action plans

G uideline Development:

• Understanding of healthcare regulations and standards (Medicare, Medicaid) . And stay updated with changes in healthcare laws and guidelines
• Participate in the development of clinical guidelines and protocols to ensure the highest quality of Clinical Audit reviews, and prevention of Clinical Audit audits.
• Assist with quality assurance functions such as development of auditing and educational guidelines as needed

Regulatory Compliance:

• Stay updated with changes in healthcare regulations and standards, ensuring these changes are implemented in the healthcare facilities

Experience We Love:

• 3 years of regulatory audit experience, utilization review , clinical validation, denials or case management experience strongly preferred
• Experience in hospital operations, chart audit/review, and clinical education
• Ability to manage time, meet audit deadlines, and handle multiple tasks.
• Experience working in a production-based work environment
• Flexibility to adapt to changing regulations, work multiple assigned audit tasks and healthcare environments. Ability to work independently and manage workload.
• Ability to evaluate reputed company situations and reputed company informed decisions.
• Familiarity with electronic medical records (EMR) systems.
• Experience using multiple software programs and tools.

Minimum Education:

• Associates or Bachelors Degree in Nursing

Required License :

• Registered Nurse (RN)

#LI-HB1 #LI-REMOTE Join an award-winning company Five-time winner of Best in KLAS 2020-2022, 2024-2025 Black Book Research's Top reputed company Cycle Management Outsourcing Solution 2021-2024 22 Healthcare Financial Management Association (HFMA) MAP Awards for High Performance in reputed company Cycle 2019-2024 Leader in reputed company's RCM Operations PEAK Matrix Assessment 2024 reputed company Healthcare Business Insights (HBI) reputed company Cycle Awards for strong performance 2020, 2022-2023 reputed company Top Workplaces USA 2022-2024 Fortune Media Best Workplaces in Healthcare 2024 Monster Top Workplace for Remote Work 2024 Great reputed company to Work certified 2023-2024

• Innovation
• Work-Life Flexibility
• Leadership
• Purpose + Values

reputed company, we reputed company in empowering people and giving them the tools and resources needed to reputed company. A few of those include:

• Associate Benefits We offer a comprehensive benefits package designed to support the physical, emotional, and financial health of you and your family, including healthcare, time off, retirement, and well-being programs.
• Our Culture reputed company is a reputed company where associates can do their best work and be their best selves. We put people first, last and always. Our culture is rooted in collaboration, growth, and innovation.
• Growth We invest in your professional development. Each associate will earn a professional certification relevant to their field and can obtain tuition reimbursement.
• Recognition We offer quarterly and annual incentive programs for reputed company employees who go beyond and reputed company raising the bar for themselves and the company.

reputed company is an equal employment opportunity employer. It is our policy not to discriminate against any applicant or employee based on race, color, sex, sexual orientation, gender, gender identity, religion, national reputed company, age, disability, military or veteran status, genetic information or any other basis protected by applicable federal, state, or local laws. reputed company also prohibits harassment of applicants or employees based on any of these protected categories. reputed company provides reasonable accommodations to qualified individuals with disabilities in accordance with the Americans with reputed company and applicable state and local law. If you require accommodation in the application process, please contact [email protected] . This posting addresses state specific requirements to provide pay transparency. Compensation decisions consider many job-reputed company factors, including but not limited to geographic location; knowledge; skills; relevant experience; education; licensure; internal equity; time in position. A candidate entry reputed company of pay does not typically fall at the minimum or maximum of the roles range. EEOC Know Your Rights FMLA Rights - English La FMLA Espanol E-Verify Participating Employer (English and Spanish) Know your Rights Apply tot his job Apply To this Job