Medical Review Clinical Appeals Auditor (RN)

About the role

Review appeals of medical audit findings, analyze new evidence, and ensure accurate documentation of appeal results. Evaluate medical records, claims data, and applicable guidelines to validate audit outcomes, provide feedback for process improvements, and support training initiatives.

Manage multiple assignments, apply clinical and coding knowledge, and maintain compliance with industry regulations in a fast-paced environment that emphasizes professionalism, collaboration, and adaptability.

Responsibilities

• Review appeals of medical audit findings
• Analyze new evidence submitted with appeals
• Document appeal results accurately
• Evaluate medical records, claims data, and applicable guidelines to validate audit outcomes
• Provide feedback for process improvements
• Support training initiatives
• Manage multiple assignments efficiently
• Apply clinical and coding knowledge to ensure compliance with industry regulations

Requirements

• Active RN license
• Extensive healthcare or auditing experience
• Strong analytical, communication, and technical skills
• Proficiency with medical coding, claims systems, and electronic medical records

Qualifications

• Demonstrated ability to make high-quality, accurate appeal determinations