3 days old

Medical Review Nurse Auditor

Performant Financial
Remote U.S. - Reports to San Angelo
  • Job Code
Performant Financial Corporation

Performant Corporation is an Equal Opportunity Employer (Minorities/Females/Disabled/Veterans).

Medical Review Nurse Auditor
Job Code:2018-50-4R-006
Location:Remote U.S. - Reports to San Angelo, TX Office
Status:Regular Full Time
The Medical Review Nurse Auditor objectively and accurately completes medical record reviews on assigned audits while meeting quality and productivity performance goals.  Makes determinations based on clinical expertise and knowledge while using audit tools and resources available.  Communicates and supports the identification of additional audit opportunities and participates in development of ideas as necessary.   

  • Conduct medical chart reviews.  Clinically validate the medical appropriateness and coding accuracy of services rendered in an inpatient setting.
  • Accurately document clinical audit determinations within the audit tracking system, and maintain thorough and objective documentation of findings.
  • Create narrative rationale to correspond audit determinations.  
  • As needed, support findings during the appeals process.
  • Serve as a clinical resource; provide clinical expertise, and clinical guidance to the team.
  • Works collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential Fraud Waste and Abuse (FWA).
  • Monitors, tracks and reports on all work conducted.
  • Consults with our clients, physicians, other clinical resources and contractors as necessary.
  • Participates in process improvement activities and encourages ownership of and group participation in improvement initiatives.
  • As needed, assist with quality assurance functions, development of medical review and coding guidelines and training.
  • Maintain a current knowledge of Medicare and Commercial regulations, policies and procedures
  • Identify and recommends opportunities for cost savings and improving outcomes.
  • Attend conference calls and meetings as requested.
  • Maintain coding certification to ensure eligibility to perform audits on behalf of Performant
  • Other duties, responsibilities, and qualifications may be required and/or assigned as necessary

Required Skills and Knowledge:

  • Knowledgeable of the uses of ICD-9, ICD-10 PCS/HCPCS/CPT, MS-DRG codes
  • Thorough working knowledge of CPT/HCPCs/ICD-9/ICD-10/MS-DRG coding
  • Familiarity with interpreting electronic medical records (EHR).
  • Knowledge of insurance programs, particularly the coverage and payment rules.
  • Ability to maintain high quality work while meeting deadlines and performance metrics.
  • Excellent organizational, interpersonal and communication skills.
  • Strong problem-solving skills.
  • Typing skills and working knowledge of computer functions and applications such as MS office (Outlook, Word, Excel).
  • Must be able to independently use standard office computer technology (e.g. email, telephone, copier, etc.) and have experience using a case management system/tools to review and document findings.
  • Acute sense of professionalism, attention to detail and confidentiality.
  • Capability of working in a fast-pace environment, flexibility with assignments and the ability to adapt in a changing environment.
  • Proficient in the use of CMS 1500/UB 04 forms.
  • Flexibility to handle any non-standard situations that may ariseAbility to multi task and work independently in a remote setting.
  • Working knowledge of encoder.


Physical requirements:

Professional business setting, sits at a desk using keyboard, mouse and monitor to perform work. Headsets provided upon request. Works assigned schedule based upon business needs (full-time 8 hours per day/ 40 hours per week, and work extended hours/overtime as required to meet business needs) and requires:

•Able to work in face paced professional business environment 
•Able to sit at desk, working on computer and phones 
•Lift/carry/push/pull under and over 10lbs occasionally
•Keying frequency, handling, reaching, fine manipulation
•Repetitive use of right/left arms and hands


Education and Experience:

  •  Active unrestricted RN license in good standing.
  • Coding Certification as a CPC, CPC-H, CPC-P, RHIA, RHIT, CCS, or CCS-P
  • 2+ years clinical review and coding/auditing experience for an inpatient facility/SNF Facility
  • 3+ years of actual MS-DRG coding in an acute facility setting
  • 2+ years direct experience in medical chart review for all provider/claim types inpatient/outpatient
  • 1-2 years experience working with health are claims demonstrating expertise in ICD-9/ICD-10 coding, HCPS/CPT-4 coding, and MS-DRG including medical billing experience for an Insurance Company or Hospital.
  • Experience in conducting medical audits, investigations, reviewing and researching post service claims for aberrant billing patters, thorough review of the medical record documentation preferred.
  • Experience with utilization management systems or clinical decision making tools such as MCG or InterQual.
  • Proven ability to review, analyze, and research coding issues, a plus but not required.
  • Reimbursement policy and/ or claims software analyst experience, a plus but not required
  • Previous experience in either a provider or payer environment in claim processing, auditing, edit development, and/or coding and reimbursement policy a plus but not required



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Medical Review Nurse Auditor

Performant Financial
Remote U.S. - Reports to San Angelo

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