Job Summary
The role focuses on auditing both inpatient and outpatient medical claims submitted to commercial and government payers. The auditor is responsible for documenting findings according to relevant policies and guidelines, as well as providing support for appeals when necessary. Emphasis is placed on collaboration for the continuous improvement of audits, medical policies, provider education, as well as quality assurance efforts and training programs.
Responsibilities
- Conduct audits of inpatient and outpatient medical claims for various payers.
- Document audit findings in compliance with applicable policies and regulations.
- Support the appeal process as required based on audit outcomes.
- Collaborate with stakeholders to enhance auditing procedures and medical policies.
- Participate in provider education initiatives.
- Contribute to quality assurance efforts and training initiatives.
- Assist in developing review guidelines and system edits.
Qualifications
- Active, unrestricted RN license in good standing.
- Minimum of five years of varied direct-care nursing experience.
- At least one year of experience in medical records review.
- One year of experience in claims processing, including coding and medical billing.
- Utilization review experience is highly desirable.
