Responsibilities
- Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
- Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
- Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
- Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
- Support fraud investigators with medical review expertise to detect and address fraudulent activities.
- Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.
Requirements
- Registered Nurse (RN)
- Coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential through AAPC or AHIMA
- Knowledge of commercial insurance plans, Medicare, and Medicaid programs
