Nurse Review Auditor (Medical)

TL;DR

Nurse Review Auditor (Medical): Performing comprehensive clinical audits to ensure medical necessity and regulatory compliance for high-complexity healthcare claims with an accent on payer guideline adherence and clinical appeals. Focus on validating DRG assignments, determining levels of care, and mitigating reimbursement risks.

Location: Remote (United States)

Company

Specialty Revenue Cycle Management provider leveraging intelligent automation to improve financial sustainability for healthcare organizations.

What you will do

• Analyze and resolve high-complexity clinical claims and denials requiring advanced clinical judgment.
• Determine appropriate admission types, levels of care, and coverage based on clinical documentation and payer rules.
• Apply CMS, InterQual, and MCG guidelines to validate reimbursement integrity.
• Perform DRG validation and line-item reviews to identify correction or appeal opportunities.
• Compose evidence-based clinical appeals using nationally recognized sources and peer-reviewed literature.
• Identify trends and risks to provide data-driven recommendations for operational improvement.

Requirements

• Active RN license with ADN or BSN required.
• Minimum 2 years of experience in Medical Necessity Reviews, DRG validation, and LCD/NCD application.
• 3-5 years of acute care hospital experience in ICU/Trauma, Surgery, Orthopedics, or Neurosurgery.
• Strong knowledge of CMS guidelines and nationally recognized medical review standards.
• Proficiency in billing and claims forms (UB, CMS, HCFA) and EMR/EHR systems.
• Must be based in the United States.

Nice to have

• Compact State licensure.
• Professional coding credentials such as AAPC or AHIMA certification (e.g., CPC, CCS, RHIA, RHIT).

Culture & Benefits

• Culture centered on professional growth and investing in employees.
• Family-oriented and flexible environment that values work-life balance.
• Recognized as a Top Workplace and one of the fastest-growing private companies in the US.
• Collaborative spirit with a genuine focus on cooperation and shared goals.