Nurse Auditor

Position Name: Nurse Auditor

Experience: 1-3 Years

About Us

Ensemble Health Partners is the single solution for a frictionless revenue cycle. Founded in 2014, we set out to redefine what is possible in healthcare by empowering people to be the difference.

Today, Ensemble supports revenue cycle excellence for hundreds of hospitals across the United States. From talent to technology, we provide a comprehensive healthcare revenue cycle management solution that enables industry leaders to achieve sustained performance and measurable outcomes.

Ensemble Health Partners India, the company's Global Capability Center with its flagship facility in Hyderabad, serves as a hub for certified professionals supporting critical revenue cycle functions across the organization.

Position Summary

This advanced clinical auditor position is responsible for reviewing assigned work queues, performing charge audits, resolving incorrect and/or missing charges on pre-bill and post-bill accounts, monitoring revenue loss reports, and identifying documentation opportunities to support accurate charge capture.

The role includes reviewing clinical documentation, identifying trends related to missing or incorrect charges, and managing Injection & Infusion work queues in Epic. The Nurse Auditor will also resolve pre-bill and post-bill charge errors identified through Opera Solutions software and collaborate with stakeholders to ensure documentation and charge capture practices meet established standards.

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 to determine whether services met coverage requirements.

Denial Investigation

• Investigate reasons for insurance denials by reviewing Explanation of Benefits (EOB) documents and remittance advice.

Coding Validation

• Analyze ICD-10 and CPT coding accuracy and identify coding-related issues that may have contributed to denials.

Appeals Process Management

Appeal Preparation

• Draft and submit detailed appeal letters with supporting medical evidence and clinical documentation.

Collaboration

• Partner with Case Management, Billing, and Coding teams to gather information and resolve issues impacting reimbursement.

Submission and Tracking

• Submit appeals within payer deadlines and monitor progress throughout the revenue cycle.

Reconsideration Requests

• Coordinate peer-to-peer reviews between physicians and insurance medical directors when required.

Trend Analysis & Prevention

• Identify recurring denial patterns and develop strategies to prevent future denials through improved documentation and process adherence.

Regulatory Compliance

• Ensure all activities comply with CMS regulations, federal and state laws, and payer-specific policies.

Education, Certifications & Experience

Required Qualifications

• Graduate in B.Sc. Nursing or M.Sc. Nursing
• Current RN or LPN Licensure
• Acute Care, Utilization Review, or Case Management experience preferred
• Strong understanding of medical necessity criteria (InterQual/MCG), DRGs, and payer requirements
• Excellent written and verbal communication skills

Preferred Certifications

Candidates must possess and maintain at least one of the following 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)