Compliance Auditor Registered Nurse
Pulse Staffing is searching for a Compliance Auditor RN for a busy Hospital located in the medical center. This is a 13 week contract. 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