Clinical Nurse Auditor
I
Integrity Management Services, Inc.Healthcare
Alexandria, Virginia, United StatesFull-TimeMiddle
Salary not disclosed
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Job Details
- Experience
- Minimum 5 years of clinical nursing experience
- Required Skills
- Microsoft Office
Requirements
- Associate’s Degree in Nursing
- Current, unrestricted Registered Nurse (RN) license
- Certification in medical coding from AAPC or AHIMA (e.g., CPC, CIC, CDI)
- Minimum 5 years of clinical nursing experience
- Experience with hospital bill auditing or defense auditing
- Strong knowledge of provider manuals, reimbursement policies, and medical policy guidelines
- Experience with healthcare fraud investigation and auditing
- Proficiency in CPT/HCPCS and ICD-10 coding
- Strong proficiency in Microsoft Office
- Familiarity with audit tracking systems
Responsibilities
- Conduct in-depth medical reviews through prepayment claims review and post-payment auditing
- Identify potential over-utilization or fraudulent activities
- Assist in the creation of audit tools, policies, procedures, and educational materials
- Serve as a liaison with service operations and other departments
- Analyze performance data to identify patterns and trends
- Collaborate with service operations to address process improvements
- Recommend modifications to medical policy
- Support fraud investigators with medical review expertise
- Act as a resource and mentor to other nurse auditors
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