Nurse Auditor Job Description

Nurse Auditor Job Description

176 votes for Nurse Auditor
Nurse auditor provides inpatient and outpatient medical/surgical care (patient history, physicial examination, ordering and interpreting medical and laboratory tests, making medical/surgical diagnoses and instituting treatment programs) with the supervisioning physician.

Nurse Auditor Duties & Responsibilities

To write an effective nurse auditor job description, begin by listing detailed duties, responsibilities and expectations. We have included nurse auditor job description templates that you can modify and use.

Sample responsibilities for this position include:

Review daily in-process report for new assigned claims
Request documentation from Office Assistant needed to complete clinical review of assigned claims
Review coding of professional bills utilizing requested procedural notes
Review itemized bill and medical records for medical appropriateness and inconsistencies by performing a line by line clinical review of claim
Research unfamiliar procedures as needed via web
Contact provider's representative to resolve billing issues
Contact provider's representative to negotiate claim
Confirm re-pricing information with provider
Provide status of outstanding claims upon request
Prepare management reports of findings for submission to clients

Nurse Auditor Qualifications

Qualifications for a job description may include education, certification, and experience.

Licensing or Certifications for Nurse Auditor

List any licenses or certifications required by the position: GOLD, CPR, CPC, BLS, ONC, CBN, MAP, CFE, AHFI, DHCS

Education for Nurse Auditor

Typically a job would require a certain level of education.

Employers hiring for the nurse auditor job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Associate Degree in Nursing, Education, Associates, Management, Healthcare, School of Nursing, Graduate, Medical, Auditing, Science

Skills for Nurse Auditor

Desired skills for nurse auditor include:

Disease process and treatment methodology and utilized at least 50% of the time
Medical terminology
Multiple software programs
Anatomy and physiology
Medications and laboratory values
Treatment protocols
Medical and surgical procedures and other healthcare practices

Desired experience for nurse auditor includes:

Monitor turnaround time to ensure timely processing of claims
Assist with provider's payment inquiries to resolve disputes
Serve as additional clinical and non-clinical resource to other members of the bill review team
Performs Telephonic and Onsite Audit validation reviews along with Chart Audits
Maintains current working knowledge, principles, government regulation, protocols admission review, post-discharge calls and discharge planning
Ensure all month end responsibilities are met, Work Force Central (WFC), Paid Time Off (PTO), Billable hours

Nurse Auditor Examples


Nurse Auditor Job Description

Job Description Example
Our innovative and growing company is looking for a nurse auditor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for nurse auditor
  • Ability to interact with the Hospital Financial Department, HIM personnel, and departmental leaders
  • Knowledge of the disease process and treatment methodology is required and utilized at least 50% of the time
  • Knowledge of ICD-9 and CPT Coding Principles billing methodologies
  • Occasional contact with patients and outsiders
  • The Nurse Auditor has access to institutional financial goals and ongoing reports supporting the achievement and benchmarks of the Finance Committee
  • Must be able to cover in absence of a Clinical Auditor
  • Must be adaptable and flexible as required
  • Regional Travel up to 20% required
  • RN with current Florida license
  • 3 years clinical hospital experience, CDM management, case management or order entry maintenance experience
Qualifications for nurse auditor
  • 3 years of auditing experience either for hospitals or insurance companies preferred
  • Perform charge reviews by verifying billing data as compared to documentation and making corrections in Patient Accounting as needed
  • Maintain billing education
  • Working knowledge of HIPPA regulations and compliance
  • Strong interpersonal and communication skills to be able to work successfully in a team-orientated environment
  • Solid knowledge of medical remittance process, claim adjudication cycle and claim denials

Nurse Auditor Job Description

Job Description Example
Our growing company is hiring for a nurse auditor. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for nurse auditor
  • Develops rationale for the audit decision based on the Provider’s submitted information, citing appropriate guidelines and/or applicable regulations, and enters clearly documented information in CAS / ProperPay
  • Audits all Emergency Department (ED) medical records, ensures all charts are coded utilizing the ED log
  • Audits ED Records utilizing provided resources
  • Reviews quality of documentation at a clinical level and records errors on the CCT (productivity measured by monthly quality review)
  • Provides education to ED staff regarding proper documentation on all FirstNet forms
  • Completes all routes of administration forms in ED upon the implementation of CPOE
  • Complete reports as assigned to ensure reconciliation processes are completed for the ED
  • Monitors ANSB, keeping number of accounts at an acceptable goal set by department leadership
  • Projects as assigned by Net Revenue Supervisor
  • Works with HIM, PFS & FEP to resolve billing, denial, and coding issues related to clinical processes
Qualifications for nurse auditor
  • Excellent working knowledge of insurance carriers’ payment regulations including various reimbursement schemes, coinsurance and deductibles and contractual adjustments
  • Knowledge of Medicare, managed care and commercial insurances
  • Working knowledge of workflow management and electronic case file systems
  • Ability to multi-task and prioritize work for self and direct reports as needed
  • Ability to display excellent interpersonal skills with a customer service focus
  • Active Nursing Diploma, Degree or Equivalent

Nurse Auditor Job Description

Job Description Example
Our company is searching for experienced candidates for the position of nurse auditor. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for nurse auditor
  • Facilitates smooth and efficient operation of department by being available and prepared to work during scheduled working hours, attending meetings as requested by management
  • Works additional hours as necessary and as requested by department management to meet AR goal and to facilitate proper ED documentation
  • RN with clinical experience considered
  • Demonstrated ability to read medical charts, and understand services being performed
  • Demonstrates Share Behaviors/Waterman Way
  • Coordinates with external audit companies and third party payers on all external audits
  • Meet with auditors, familiarize them with Swedish records, policies, , answer questions and be available as they conduct audits
  • Review audit findings, obtain further documentation from hospital departments, and check accuracy of findings
  • Assist Patient Financial Services staff in regards to edits in Epic and Emdeon or other third party claims editing systems
  • Finalize and sign-off with auditors on agreed upon final audit reports
Qualifications for nurse auditor
  • 1-3 years of medical management experience performing utilization
  • 3-5 years of medical management experience within a managed care organization
  • Knowledge of CMS Medicare Part A, B, & C billing and regulations
  • Advanced experience with national evidence based screening guidelines (MCG, formerly Milliman Care Guidelines
  • Advanced clinical documentation review or audit experience which may include case management, utilization review or clinical documentation improvement
  • Post-pay reimbursement audit experience

Nurse Auditor Job Description

Job Description Example
Our company is searching for experienced candidates for the position of nurse auditor. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for nurse auditor
  • Works direct with providers to identify level, intensity and duration of care
  • Documents findings, continues to evaluate medical necessity for frequency, intensity and length of required
  • Assures that the consistency and quality of reviews meets or exceeds industry standards
  • Works to ensure quality reviews are completed within the required client, federal and state or URAC mandated turnaround times
  • Maintain and apply knowledge of URAC and other state and federal regulatory requirements
  • Maintains accurate record of Utilization Reviews within the appropriate database
  • Direct Customer Service Representatives to ensure timely delivery of determination letters
  • Assists in resolution of client complaints and/or quality assurance issues as needed
  • Ensures all quality assurance standards and federal ERISA, URAC, and/or other state guidelines are adhered to at all times
  • Assist with the Claims Selection Process for audit
Qualifications for nurse auditor
  • Ability to independently set and organize own work priorities for self, and successfully adapt to new priorities as part of a changing environment
  • Ability to travel to conduct onsite Provider reviews as requested
  • Nursing Certification/Licensure required
  • Computer skills - navigation and edit resolution through various Web based systems
  • At least 5 years of experience to include time as a care giver auditor
  • Two years clinical experience in a hospital

Nurse Auditor Job Description

Job Description Example
Our company is growing rapidly and is hiring for a nurse auditor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for nurse auditor
  • Research unfamiliar procedures via web, as needed
  • Research high-cost pharmaceutical products utilizing all applicable tools and software
  • Present recommended findings including all supportive documentation and saving recommendations to client
  • Provides written and/or verbal feedback internally to assist with performance improvement
  • Develops reporting and overall performance trend identification
  • Analyzes overall trends based on monitoring results to identify enterprise improvement opportunities
  • Utilizes trend results to identify areas for which more intensive monitoring should be implemented
  • Reviews client reports to ensure that data is accurate and conducts follow up as needed to populate missing data elements
  • Perform case reviews to ensure that client, accreditation and regulatory requirements are met
  • Utilizes assigned work queues in the billing system, COMPAS and Charge Audit Tool to perform pending audits and assists Reimbursement RID Services with administrative duties
Qualifications for nurse auditor
  • Computer proficient with MS Office products including
  • Registered Nurse - NH State or Valid Nursing License in another Compact State
  • Must hold and maintain an unencumbered Registered Nursing license
  • This position is open to internal candidates located within any LOB within the enterprise
  • Current and unrestricted RN license, preferred
  • 1-2 years of specific clinical knowledge and experience in Utilization Management with in a managed care organization

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