Nurse Auditor

Nurse Auditor

Portland, OR

Exp 5-7 years

This position can be located in Tacoma, WA; Seattle, WA; Burlington, WA; Salt Lake City UT; Medford, OR; Portland, OR; Lewiston, ID

Candidates must work at least 6 months in the office before telecommute work will be considered

Job Purpose
•Plan, coordinate, conduct and report on post payment claims audits and performs related special projects as assigned.

Key Qualifications and Experience:
•Proven knowledge of medical and surgical procedures and other healthcare practices and trends.
•General computer skills (including use of Microsoft Office, specifically Excel and Outlook, internet search).
•Familiarity with health care documentation systems.
•Strong verbal, written and interpersonal communication and customer service skills.
•Ability to communicate audit outcomes and testing results with other staff within the company who are both medically and non-medically oriented.
•Ability to interpret policies and procedures and communicate complex topics to others.
•Strong organizational and time management skills with the ability to manage workload independently.
•Ability to think critically and make decisions within individual role and responsibility.
•Proven ability in developing and following an audit program.
•Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).

Normally to be proficient in the competencies listed above:
•Nurse Auditor would have a/an Associate or Bachelor’s Degree in Nursing or related field and 5 years of hospital quality management, coding or medical auditing experience or equivalent combination of education and experience.

Required Licenses, Certifications, Registration, Etc.
•Registered nurse (RN) license (must have a current unrestricted RN license for medical care management).
•Certified Coder certified with the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA) preferred.

General Functions and Outcomes:
•Applies clinical expertise and judgment to ensure payments comply with medical policy, medical necessity guidelines, and accepted standards of care.
•Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
•Understands and analyzes complex provider and hospital contracts in order to ensure payments are for covered services.
•Conducts coding audits, quality assurance assessments of claims, reviews statistical samples and analyzes for risk.
•Conducts surveys of complex audit areas to define the scope and objectives of audits. Assists in the development of overall audit plans, including comprehensive audit programs that identify specific procedures and tests designed to achieve the audit objectives.
•Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts.
•Responds in writing or by phone to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
• Provides consistent and accurate documentation.
•Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals

Skills and Certifications
RN license in either WA, OR, ID, UT
Certified Professional Coder preferred



Ideal Candidate We have several positions open, with one being specific for working with Skilled Nursing Facilities. We would prefer candidates with specific experience in Skilled Nursing Facilities or a varied skill set in a clinical setting, with chart auditing experience strongly preferred.
Ideal Candidate should have worked for the following company(ies): Any other health insurance plan