Compliance Auditor Registered Nurse

Bellaire, TX

Posted: 06/11/2019 Employment Type: Contractor Industry: Nurse, Health Care Job Number: JCL6KS666BTRJ1R2QYL

Pulse Staffing is searching for a Compliance Auditor RN for a busy Hospital located in the medical center. This is a temp to permanent assignment. Mon-Fri 8a-5p.

Medical Compliance Auditor Responsibilities:

  • Assess the treatment plan, clinical information, and medical necessity of all requested services.
  • Perform Clinical and Coding Review on Medical Claim Appeals. Responsibility
  • Assess and process all education and recoupment letters after Special Investigative Committee review decision
  • Perform Clinical Review and make recommendation on Audit Pass/Fail.
  • Research Texas Medicaid Programs
  • Develop audit criteria for each case
  • Perform medical record reviews for potential fraud and abuse cases for members and providers
  • Develop an audit grid to track criteria for each date of service
  • Develop report with rules applied and findings for each case

Required: Bachelor's Degree in Nursing, RN - License-Registered Nurses, 2 years RN, medical auditing, and/or managed care experience

Must have 5 years of Medical audit background

Utilization Review experience

Experience with Texas Medicaid Program

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