Registered Nurse Clinical Auditor

Position Overview

This fully remote position seeks a meticulous Registered Nurse to perform medical record evaluations and billing compliance audits related to Indiana Health Coverage Programs. The role focuses on assessing care quality, reviewing records and program policies, identifying compliance concerns, preparing audit documentation, and assisting with appeals. Occasional travel within Indiana may be necessary.

Primary Responsibilities

• Examine medical records and accompanying documents to assess provider compliance with Indiana Health Coverage Programs, CMS, AMA, and relevant regulatory standards.
• Independently conduct medical record and compliance audits, reporting preliminary conclusions to the Lead Reviewer.
• Detect documentation shortcomings and billing compliance issues.
• Maintain comprehensive workpapers detailing procedures, reviewed records, findings, and resultant conclusions.
• Support audit response efforts and appeal proceedings as needed.
• Ensure all activities comply with state, federal, and national Medicaid and healthcare regulations.
• Keep informed about clinical guidelines, policies, regulations, and updates specific to Indiana Medicaid programs.
• Research and maintain internal repositories of Indiana Medicaid bulletins, policies, and procedures.
• Adapt swiftly to evolving priorities, regulatory changes, and audit requirements while upholding accuracy and deadlines.

Qualifications

• Preferred RN license; Indiana or compact license holders accepted.
• Strong preference for candidates with coding certification such as CCS or CPC.
• Preference given to candidates located in or near Indianapolis, Indiana.
• Minimum of one year experience in Medicaid claims review, billing compliance, or healthcare reimbursement.
• Familiarity with Indiana Medicaid policies, payer guidelines, and documentation standards preferred.
• Understanding of CPT coding standards and ICD-10 regulations.
• Proficiency in Microsoft Excel, Word, and Outlook.
• Excellent analytical, critical thinking, problem-solving, and technical writing abilities.
• Able to work both independently and collaboratively in a dynamic environment.
• Experience working alongside healthcare providers is highly valued.
• Knowledge of healthcare claims data and fraud, waste, and abuse identification is preferred.