Nurse Auditor

About the Role

Rising Medical Solutions is seeking a Nurse Auditor to review medical bills from a clinical perspective, ensuring appropriate billing, coding, treatment, fee schedule compliance, and identifying over-utilization or erroneous charges. This role supports our mission of medical cost containment by providing clients with the information needed to determine case value through detailed evaluation of medical records and billing statements.

Responsibilities

• Audit medical and billing records to determine if services provided are reasonable, appropriate, and necessary.
• Clinically identify and evaluate charges not related to the occurrence.
• Verify that charges align with services ordered and authorized.
• Initiate contacts with clients and medical providers as needed.
• Negotiate bills and conduct re-evaluation reviews when required.
• Maintain a human touch, demonstrating sensitivity to diverse situations and individuals.

Qualifications

• Active RN (or LPN) license or equivalent within states of operation.
• CPC and/or CPC-H certification(s) strongly desired.
• Specialized training in hospital coding, orthopedics, neurology, rehabilitation, or ER procedures.
• 3-5 years of clinical experience in acute care, surgery, and/or orthopedics.
• Workers’ Compensation medical bill review experience is a major plus.
• Understanding of CPT and ICD-10 codes and Medicare guidelines.
• Ability to apply knowledge to state fee schedules.
• Strong customer service orientation with excellent communication skills.
• Experience in deposition or litigation cases is a plus.