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Nurse Review Auditor (REMOTE)

3 hours, 41 minutes ago
United States
Full-time
Mid Level
Operations Analyst
Operations
Apply Now
EnableComp

EnableComp

EnableComp specializes in complex claims and specialty revenue cycle management solutions for healthcare providers, focusing on optimizing reimbursements for various claims types, including VA, Workers' Compensation, and Motor Vehicle Accidents, throug...

Insurance
251-1K
Founded 2000
View All Jobs 11

Description

  • Review, analyze, and resolve high-complexity claims and denials using advanced clinical judgment and payer-specific rules.
  • Determine admission type, level of care, length of stay, care setting, and coverage based on clinical documentation.
  • Apply CMS, InterQual, MCG, LCD/NCD, and payer-specific medical review guidelines and standards.
  • Perform line-item reviews to validate claim accuracy, compliance, and reimbursement integrity.
  • Review DRG assignments and downgrades to identify opportunities for support, correction, or appeal.
  • Document clear clinical opinions, conclusions, and recommendations supported by evidence.
  • Prepare high-quality clinical appeals with documentation from recognized sources such as CMS, peer-reviewed literature, InterQual/MCG, and specialty society guidance.
  • Identify trends, risks, and educational opportunities from audit findings.
  • Communicate audit results, clinical rationale, and recommendations to internal leadership and external partners.
  • Collaborate with domestic and international teams to support consistent medical review standards, audit methodology, and best practices.

Requirements

  • Active RN license with an ADN or BSN is required.
  • Compact State licensure is preferred.
  • Minimum of 2 years of experience in medical necessity reviews, admission/length of stay reviews, LCD/NCD interpretation, DRG validation and downgrade reviews, and line-item reviews.
  • 3-5 years of acute care hospital experience in ICU, trauma, surgery, orthopedics, neurosurgery, or a related area.
  • Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
  • Advanced analytical ability and strong attention to detail.
  • Excellent written and verbal communication skills.
  • General computer skills, including Microsoft Office, especially Excel and Outlook, plus internet search ability.
  • Demonstrated competency in claim review and use of billing and claims forms such as UB, CMS, and HCFA.
  • Familiarity with EMR/EHR systems and the ability to navigate electronic medical records across multiple platforms.
  • AAPC and/or AHIMA coding credentials such as CPC, CCS, RHIA, or RHIT are a plus.

Benefits

  • Remote work environment.
  • Full-time employment status.
  • Opportunities for professional growth and development.
  • Supportive workplace culture focused on employee growth.
  • Tools, resources, and support to help employees thrive in their careers.
  • Flexible and family-oriented work culture, based on employee testimonials.

Interested in this position?

Apply directly on the company website

Apply Now

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