Registered Nurse Clinical Auditor

Key Responsibilities

• Review medical records and related documentation to evaluate provider compliance with Indiana Health Coverage Programs, CMS, AMA, and other applicable standards and regulations.
• Conduct medical record and compliance reviews independently and provide preliminary findings to the Lead Reviewer.
• Identify potential documentation deficiencies, and billing compliance issues.
• Maintain detailed workpapers documenting procedures performed, records reviewed, findings identified, and conclusions reached.
• Assist with audit responses and appeals as needed.
• Ensure all work aligns with state, federal, and national healthcare and Medicaid guidelines.
• Stay current on clinical guidelines, policies, regulations, and Indiana Medicaid program and policy updates.
• Research Indiana Medicaid rules and maintain internal repositories of bulletins, policies, and procedures.
• Adapt quickly to changing priorities, policies, regulatory updates, and review requirements while maintaining accuracy and meeting deadlines.

Requirements

• RN license preferred; Indiana license or compact license accepted.
• Coding certification such as CCS or CPC strongly preferred.
• Candidate located in or near the Indianapolis area is preferred.
• At least 1 year of Medicaid claims review, billing compliance, or healthcare reimbursement experience.
• Familiarity with Indiana Medicaid policies, payer guidelines, and documentation requirements preferred.
• Knowledge of CPT coding guidelines and ICD-10 standards.
• Proficiency in Microsoft Excel, Word, and Outlook.
• Strong analytical, critical thinking, problem-solving, and technical writing skills.
• Ability to work independently and collaboratively in a fast-paced environment.
• Experience working with healthcare providers is strongly preferred.
• Knowledge of healthcare claims data and fraud, waste, and abuse preferred.