Clinical Auditor I-Nurse

Job Summary

The Clinical Auditor I performs detailed medical record audit review and analysis of the health plan’s outpatient, professional and ancillary claims to ensure accurate reimbursement and adherence to regulations.

Key Functions/Responsibilities

• Analyze patient records, treatment plans, and medical billing documents to ensure accuracy, completeness, and strict compliance with healthcare standards and regulations.
• Verify that procedures and diagnoses are accurately coded using appropriate CPT, HCPCS, and ICD-10 codes.
• Ensure that the coding reflects the clinical documentation accurately and complies with current guidelines.
• Check for consistent documentation across patient records, confirming that all entries adhere to regulatory mandates, internal policies, contract stipulations, and benefit coverages.
• Identify any documentation or billing discrepancies during the review process. This includes spotting errors, omissions, or inconsistencies that may affect reimbursement or patient care quality, and flagging these issues as needed.
• Update and refine clinical audit guidelines and protocols based on audit findings.
• Use statistical and analytical methods to examine clinical data and identify discrepancies and irregularities that could indicate non-compliance with internal policies, contractual obligations, or regulatory mandates.
• Monitor and document recurring patterns or anomalies in clinical data to determine potential areas of risk that might adversely affect patient care or disrupt the organization’s operations.
• Provide well-founded recommendations for new audit projects based on data analysis.
• Conduct both scheduled and ad hoc audits in strict accordance with established guidelines and internal processes.
• Develop comprehensive audit reports that clearly outline all findings, detailing discrepancies, process inefficiencies, and actionable recommendations for improvement.
• Support the amendment and appeals process by coordinating with providers to resolve discrepancies and ensuring audit conclusions are fully and fairly reviewed.
• Finalize all audits by ensuring all findings are documented, follow-up actions are clearly communicated, and the entire process meets established timelines and productivity standards.
• Collaborate with clinical staff, audit coordinator, and other members of the audit team on audit findings and questions.
• Maintain active communication with providers by preparing precise documentation, responding promptly to emails and phone calls, and offering detailed explanations of audit results.
• Ensure that any audit denial rationale is clearly, concisely, and accurately communicated.
• Continuously monitor evolving federal and state healthcare regulations and engage in regular education and policy reviews to ensure alignment with current regulatory requirements and best practices.
• Evaluate clinical and reimbursement activities to determine payment compliance under WellSense clinical and reimbursement policies.
• Proactively identify potential fraud and abuse by scrutinizing clinical data, documenting billing errors, and highlighting opportunities to manage benefit costs and secure savings.
• Report potential quality of care or utilization issues during audits to management.
• Aid in educating clinical personnel on documentation requirements and audit practices to enhance compliance and overall patient care quality.

Qualifications

• Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required.
• Two years CM, UM, claims auditing or other clinical health insurance role.
• Two years minimum RN experience in acute care setting.
• Behavioral Health and/or Inpatient DRG experience required.
• Certification: Or Conditions Of Employment Valid Registered Nurse License required.
• Coding Certification: Preferred - CPC or CCS certification.
• Basic familiarity with CPT, ICD-10 and HCPCS coding is preferred.
• Claims processing experience is preferred.

Compensation Range

$64,000 - $93,000

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.