Nurse Auditor

Position Name: Nurse Auditor

Experience: 1-3 years

About Us

Ensemble Health Partners - The single solution for a frictionless revenue cycle. We were founded in 2014 with the purpose of redefining the possible in healthcare by empowering people to be the difference. Since then, we’ve grown to support revenue cycle excellence for hundreds of hospitals.

From talent to technology, we at Ensemble provide a single-solution healthcare to industry leaders, enabling them to reach peak RCM performance persistently.

Ensemble Health Partners, India — the company’s Global Capability Center with its flagship facility in Hyderabad serves as a hub for certified professionals managing revenue cycle functions for Ensemble.

Position Summary

Advanced clinical auditor position that is responsible for reviewing all assigned work queues, perform charge audits, resolution of all incorrect and/or missing charges on prebill and post bill, monitoring & resolving revenue loss reports, assigned work queues, and identifying opportunities for any additional documentation needs to support captured charges.

Reviewing clinical documentation, identifying trends for missing and/or incorrect charges. Responsible for reviewing Injection & Infusion work queues in Epic. Resolve prebills and post bill missing and error charges identified by Opera Solutions software. Clinical knowledge to educate stakeholders on standards for documentation and charge capture practices.

Job Responsibilities

Medical Necessity Evaluation:

Acute care experience and Utilization Review or Case Management experience are typically required.

Strong understanding of medical necessity criteria (InterQual/MCG), coding (DRGs), and insurance policies.

Review denied claims, patient charts, provider notes, and diagnostic tests against evidence-based criteria (e.g., InterQual or Milliman Care Guidelines) to determine if the denied service met criteria for coverage.

Denial Investigation: Investigate why insurance denied services, examining Explanation of Benefits (EOB) and remittance advice.

Coding Validation: Analyze ICD-10 and CPT codes for accuracy, identifying errors that may have contributed to the denial.

Appeals Process Management

Appeal Preparation: Draft and submit detailed appeal letters, supplying medical evidence and supporting documentation, such as InterQual or Milliman Care Guidelines, to validate services.

Collaboration: Work with case management, billing, and coding departments to gather information and address coding errors.

Submission and Tracking: Submit appeals within strict payer deadlines and track progress through the revenue cycle.

Reconsideration Requests: Initiate peer-to-peer reviews between hospital physicians and insurance medical directors.

Trend Analysis & Prevention: Identify common denial reasons (e.g., lack of medical necessity, documentation issues) to develop preventative strategies.

Regulatory Compliance: Ensure all actions comply with CMS regulations, federal/state laws, and payer policies

This document is not an exhaustive list of all responsibilities, skills, duties, requirements, or working conditions associated with the job. Associates may be required to perform other job-related duties as required by their supervisor, subject to reasonable accommodation.

Education, Certifications & Experience

Experience: Acute care experience and Utilization Review or Case Management experience typically required.

Knowledge: Strong understanding of medical necessity criteria (InterQual/MCG), coding (DRGs), and insurance policies.

Communication: Excellent written communication to draft formal appeals and verbal communication for negotiations.

Graduate in B.Sc./M.Sc. Nursing with current RN or LPN Licensure

Preferred Certifications: Candidate must have and keep current at least one of the following professional certifications or other approved job relevant certifications:

• CCDI (Certified Clinical Documentation Improvement)

• CCS (Certified Coding Specialist)

• RHIA (Registered Health Information Administrator)

• RHIT (Registered Health Information Technician)

• COC (Certified Outpatient Coder)

• PMP (Project Management Professional)

CPMA (Certified Professional Medical Auditor)