Advanced RN Auditor Reviewer

This role supports the Denial, Prevention, and Recovery Department by providing expert clinical data analysis and review services. The Advanced RN Auditor Reviewer is responsible for appeal writing, conducting thorough reviews, and other duties as assigned by the Denial and Prevention Director. Acting as a liaison between auditors and external resources, this position evaluates denial trends, identifies high-risk areas, and delivers educational initiatives.

Essential Duties and Responsibilities

• Retrieve patient medical records and compile all requested documentation according to CMS guidelines and deadlines.
• Track audit requests, appeals, due dates, and correspondence while maintaining communication with payers and auditors.
• Prepare and present detailed reports for the Denial & Prevention Department.
• Write appeals, collaborate with providers to obtain letters of medical necessity, and review records for medical necessity compliance.
• Manage departmental correspondence, mail, and tracking spreadsheets.
• Cross-train in other departmental roles, including insurance review and case management.
• Develop and deliver front-end education and training related to denials.

Education

Graduation from an accredited Associate or Bachelor's Nursing program is required. Proficiency in Microsoft Excel is highly preferred.

Experience

A minimum of three years of clinical experience is necessary. Experience in utilization management, discharge planning, and working with third-party payors is preferred. Candidates must be computer literate and understand psycho-social patient needs.

Certification and Licensure

Active RN licensure from a Compact State or equivalent is required. Case Management certification is preferred.

Mental and Physical Requirements

This position demands considerable mental focus and the ability to communicate detailed information effectively both orally and in writing. Strong interpersonal and organizational skills are essential. Physical tasks include lifting up to 35 lbs., frequent walking, standing, turning, carrying, pushing, pulling, stooping, crouching, twisting, and reaching.

Working Conditions

There is occasional exposure to infectious diseases and potentially hostile individuals. Frequent contact with communicable diseases through blood and bodily fluids occurs. Physical discomfort is minimal.

This opportunity is based in a regional healthcare system serving a multi-county area in the Midwest, offering a supportive team environment, excellent benefits, and growth potential.