Nurse Auditor

We are looking for a strong clinical nurse auditor to become part of our fast growing government-based healthcare practice … Integrity Self-Motivated Team Player Results Oriented Reliable Professional Nurse Auditor wanted Established in 2005, our audit firm, based in the Baltimore County, MD area is dedicated to health care compliance of government providers, health plans and contractors. Government health care compliance services represent a large portion of our firm’s clients. We audit some of the largest & most complex health care organizations in the country utilizing a team approach drawing on various areas and levels of expertise. As a Nurse Auditor on our Assurance Team, you will be involved with performance audits, examinations and agreed-upon procedure engagements. You will also apply your experience and knowledge of patient care and/or operational processes by making suggestions to improve client internal controls and operational procedures. Position Summary: Nurse Auditor The Nurse Auditor is a clinically experienced professional who has a strong background in patient care, patient delivery systems and/or familiarity with Medicare’s coding guidelines. The Nurse Auditor will participate in audits of Part C Organization Determinations, Appeals and Grievances (ODAG), Special Needs Plan Model of Care (SNP MOC), and/or Programs of All-Inclusive Care for the Elderly (PACE). The position is responsible for reviewing policies and procedures, internal controls, and claims / medical records to determine an organization’s compliance with Medicare rules and regulations. Extensive training will be provided along with working on various teams to gain direct experience on the process. Requirements Must be a Registered Nurse with a current license, and clinical documentation, medical necessity, and/or utilization review experience. Bachelor’s degree in nursing with 5+ years related healthcare experience and a broad knowledge of medical claims billing/payment required. Direct experience in medical chart review for inpatient claims and Part C Access. Experience with medical necessity determinations applying clinical judgment, utilizing medical necessity criteria and screening tools based on nationally recognized tools. Familiarity with Coverage Determinations, Reconsiderations, Appeals and/or Grievance processes and regulations. Prior auditing experience in either a provider or payer environment. Working knowledge of DRG, ICD-9/10, CPT and HCPCS codes. Working knowledge of provider billing guidelines, payer reimbursement policies and related industry-based standards. Proficient with Word and Excel. Job Type: Full-time, The nurse auditor position is a hybrid-remote position. Initial and periodic training will be performed at David-James’ offices. Limited travel to auditee locations may be required. Salary: $75,000.00 – $85,000.00 per year #J-18808-Ljbffr