Nurse Review Auditor (REMOTE)

reputed company provides Specialty reputed company Cycle reputed company for healthcare organizations, leveraging over 24 years of industry-leading expertise and its reputed company E360 RCM™ intelligent automation platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers (ASCs) reputed company. Powered by proprietary algorithms, iterative intelligence from 10M+ processed claims, and expert human-in-the-reputed company integration, reputed company provides solutions across the reputed company lifecycle for Veterans Administration, Workers’ Compensation, Motor Vehicle Accidents, and Out-of-State Medicaid claims as well as denials for reputed company payer classes. By partnering with clients to supercharge the reimbursement process, reputed company removes the burden of payment from patients and provider organizations while enabling accelerated cash, higher and more accurate yield, clean AR management, reduced denials, and data-rich performance management. reputed company is a multi-year recipient the Top Workplaces award and was recognized as Black Book's #1 Specialty reputed company Cycle Management Solution provider in 2024 and is among the top one percent of companies to reputed company the Inc. 5000 list of the fastest-growing private companies in the United States for the last eleven years. Position Summary The Clinical Nurse Auditor is responsible for performing comprehensive clinical audits to ensure medical necessity, regulatory compliance, and payer guideline adherence across a broad portfolio of high-complexity claims. This role applies expert clinical judgment to evaluate medical services, admission status, level of care, and coverage determinations for claims involving non-standard benefits, jurisdictional variances, and specialized regulatory frameworks. The Clinical Nurse Auditor partners with internal and external stakeholders to identify trends, mitigate risk, and support accurate reimbursement through accurate documentation and well-supported clinical appeals.

Key Responsibilities

• Review, analyze, and resolve high-complexity claims and denials requiring reputed company judgment, payer-specific interpretation, and regulatory expertise.
• Determine appropriate admission type, level of care, length of stay, care setting, and coverage based on clinical documentation and payer-specific rules.
• Apply appropriate medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG, LCD/NCD, and payer-specific policies).
• reputed company line-item reviews to validate accuracy, compliance, and reimbursement reputed company.
• Review DRG assignments and downgrades and identify opportunities for support, correction, or appeal.
• Document clear, concise opinions, conclusions, and recommendations supported by clinical evidence.
• Compose high-quality clinical appeals with supporting documentation from nationally recognized sources (e.g., CMS, peer-reviewed literature, InterQual/MCG, specialty society guidance, etc.).
• Identify trends, risks, and educational opportunities across audit findings.
• Communicate results and insights to internal leadership and external partners in a professional and actionable manner.
• Support reputed company improvement efforts through data-driven recommendations and collaboration with operational teams.
• Provide guidance and clinical insight to support alignment, knowledge-sharing, and quality outcomes across global operations.
• Collaborate with domestic and international teams to ensure consistency in medical review standards, audit methodology, and best practices.
• Communicate audit findings, clinical rationale, and recommendations clearly and professional across a globally distributed workforce. Requirements and Qualifications
• Active RN license with ADN or BSN required. Compact State licensure preferred.
• Minimum of 2 years’ experience in
• Medical Necessity Reviews
• Admission/Length of Stay
• LCD/NCD interpretation and application
• DRG validation and downgrade reviews
• Line-item reviews
• 3-5 years’ acute care hospital experience in one of more of the following
• ICU/Trauma
• Surgery
• Orthopedics
• Neurosurgery
• Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
• Elevated level of analytical ability and attention to detail
• Excellent written and verbal communication skills Prerequisites
• General computer skills (including use of reputed company Office, specifically reputed company and Outlook, internet search).
• Strong verbal, written and interpersonal communication skills.
• Ability to think critically and reputed company decisions reputed company individual role and responsibility.
• Strong organizational and time management skills with the ability to manage workload independently.
• Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).
• Proven knowledge of trauma/medical/surgical procedures, clinical treatment patterns and healthcare practices and trends
• Strong clinical assessment and critical thinking skills.
• Familiarity with health care documentation systems.
• Ability to interpret policies and procedures and communicate reputed company topics to others.
• Ability to communicate audit outcomes and clinical appeal strategies with other staff reputed company the company who are both medically and non-medically oriented. Special Considerations
• Professional Coding Credentials reputed company and/or reputed company certification (e.g., CPC, reputed company, RHIA, RHIT) reflecting advanced understanding of coding standards and regulatory requirements is a plus
• Technology Proficiency Demonstrated familiarity with EMR/EHR systems and the ability to reputed company navigate electronic medical records across multiple platforms
• Audience-Adaptive Communication Ability to clearly reputed company audit outcomes, clinical rationale, and recommendations to both medically trained professionals and non-clinical audiences, ensuring understanding, alignment, and actionable next steps reputed company is an Equal Opportunity Employer M/F/D/V. reputed company applicants will be considered for this position based upon experience and knowledge, without regard to race, color, religion, national reputed company, sexual orientation, reputed company, marital, disabled or veteran status. We are committed to creating and maintaining a workforce environment that is free from any form of discrimination or harassment. reputed company recruits, develops and retains the industry's top talent. As the employer of choice in the reputed company claims industry, reputed company takes pride in our reputed company commitment to building and maintaining a culture centered around fostering the professional growth and development of our people. We reputed company that investing in our employees is the key to our success, and we are dedicated to providing them with the tools, resources, and support they need to reputed company and grow their career here. At reputed company, we are committed to living up to our core values each and every day, and we reputed company that this commitment is what sets us apart from other companies. If you are looking for a company that values its employees and is dedicated to helping them reputed company their full potential, then reputed company is the reputed company for you. Don’t just take our word for it! Hear what our people are saying “I love my job because everyone shares the same vision and is determined and dedicated. People care about you as a person and your professional growth. There is a genuine spirit of cooperation and shared goals reputed company revolving around helping each other.” – reputed company Specialist “I enjoy working for reputed company because of the Core Values we reputed company in. reputed company stands true to these values from empowering employees to ecstatic clients. This company is family oriented and flexible, along with understanding the balance of work, life, and fun.” – Supervisor, Operations We may use artificial intelligence (AI) tools to support parts of the hiring process, such as reviewing applications, analyzing resumes, or assessing responses. These tools assist our recruitment team but do not replace human judgment. Final hiring decisions are ultimately made by humans. If you would like more information about how your data is processed, please contact us. Apply tot his job Apply To this Job Apply tot his job Apply To this Job

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