RN Nurse Auditor

About the role

The RN Nurse Auditor is a key member of the Clinical Appeals team and reports directly to the Clinical Appeals Manager. This role is responsible for conducting clinical reviews of payer audit determinations, identifying improper denials, and preparing detailed appeals that support the validity of charges and medical necessity of services rendered. Utilizing strong clinical judgment, in-depth knowledge of payer policies, and regulatory compliance standards, the RN Nurse Auditor advocates for appropriate reimbursement and contributes to the financial health of the organization.

Responsibilities

• Conduct clinical reviews of payer audit determinations, identifying improper denials, and preparing detailed appeals that support the validity of charges and medical necessity of services rendered.
• Utilize strong clinical judgment, in-depth knowledge of payer policies, and regulatory compliance standards to advocate for appropriate reimbursement and contribute to the financial health of the organization.
• Identify denial trends, conduct root cause analysis, and produce actionable reports to drive continuous improvement across Revenue Cycle operations.
• Collaborate with Hospital Patient Accounting, Revenue Integrity, Case Management, Utilization Review, Compliance, and clinical departments to mitigate denial risks, provide education, and ensure clinical documentation supports reimbursement integrity.

Requirements

• Education: Bachelor's degree in Nursing from an accredited school of nursing and a minimum of three years related nursing experience required.
• Demonstrated knowledge of payer reimbursement for both governmental and managed care payers required.
• Excellent written and verbal communication skills necessary.

Qualifications

• Licensure as a Registered Nurse by the South Carolina Board of Nursing or compact state required.
• Current American Heart Association (AHA) Basic Life Support (BLS) certification or American Red Cross BLS for Healthcare Providers certification is required.

Skills

• Strong clinical judgment
• In-depth knowledge of payer policies
• Regulatory compliance standards
• Excellent written and verbal communication skills

Benefits

Not specified

Pay

Salary

Schedule

Rotating shifts