Clinical Nurse Auditor

Gaithersburg, MD
Aug 01, 2016
Feb 02, 2018
Audit and Tax, Nurse
Full Time
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Care, Compassion, Community.


Manages payer recovery activity response, including RAC and other government contractors and agencies, in responding to denials and requests for additional data requests (ADRs) in an accurate and timely manner. Includes the performance of billing and medical necessity audits to appeal medical necessity denials, as well as to ensure compliance with all regulatory bodies and organizational policy and procedure. Manage and train the government audit response staff in coordinating payer/contractor response and providing tracking, reporting, research, system and general support. Assist AHC management in the development of corrective action plans as required.


Current RN License in the State of Maryland. Experience of 5-7 years in hospital claims audits and denials appeals and/or case management.

Knowledge of InterQual, Milleman and Robertson and CMS Criteria and CMS regulations.

Knowledge of best practices in risk management and clinical documentation.

Knowledge of DRG, APG, ICD-9, and HCPCS coding highly desirable, or willingness to

learn fundamentals of coding.

Understanding of level of care requirements for inpatient and outpatient. )observation, extended recovery)

Knowledge of Medicare rules and regulations and able to access the site

Plan and implement educational material relating to topics related to Medicare and government audits.

Comfortable with Microsoft office: PowerPoint, Excel and Word.

Good communication skills both verbal and written

Prior management level experience.

Ability to research issues/topics and disperse information.

Preference: case management or utilization review background.

Preference: experience with the appeal process-government payer

Work Schedule


Tobacco Statement

Tobacco use is a well-recognized preventable cause of death in the United States and an important public health issue. In order to promote and maintain a healthy work environment, Adventist HealthCare will not hire applicants for employment who either state that they are nicotine users or who test positive for nicotine use.

Adventist HealthCare will withdraw offers of employment to applicants who test positive for Cotinine (nicotine). Those testing positive for cotinine are given the opportunity to re-apply in 90 days, if they can truthfully attest that they have not used any nicotine products in the past ninety (90) days and successfully pass follow-up testing.

Equal Employment Opportunity

Adventist HealthCare is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected veteran status.

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