Nurse Auditor

Graduation from an accredited school of nursing; three (3) years' experience in clinical nursing; and two (2) years of utilization management or other chart auditing experience.

Licensing/Certification Requirements: 

Valid state license as a Registered Nurse.

Additional Position Requirements

• Experience submitting Nevada Medicaid Authorizations Requests

• Knowledge of CMS Coding/Billing requirements 

• EPIC Experience

• Previous Utilization Management Experience

• Experience in Chart Auditing

• Experience in developing denial appeal responses

Knowledge, Skills, Abilities, and Physical Requirements

Knowledge of: 

Medical review, chart audits, and quality improvement processes; compliance regulations related to documentation, coding, and billing requirements; clinical pathways, disease state management and utilization review criteria; Medicare/Medicaid guidelines and other relevant regulations and standards; HIPAA Privacy and Security Rules; auditing concepts and principles; reviewing medical records and coding documents according to standard practice; department and hospital safety practice and procedures; patient rights; age specific patient care practices; infection control policies and practices; handling, storage, use and disposal of hazardous materials; department and hospital emergency response policies and procedures.

Skill in: 

Analyzing and evaluating medical information and applying clinical review guidelines or judgement to make clinical determinations; reviewing and verifying accuracy of data; reviewing medical records and coding documents according to standard practice; using initiative and independent judgment within general policy guidelines; multi-tasking in a fast-paced working environment; preparing clear and concise reports, correspondence and other written materials; using computers and related software applications; communicating with a wide variety of people from diverse socio-economic and ethnic backgrounds; establishing and maintaining effective working relationships with all personnel contacted in the course of duties; efficient, effective and safe use of equipment.

Physical Requirements and Working Conditions:

Mobility to work in a typical office setting and use standard equipment, stamina to remain seated for extended periods of time, vision to read printed materials and a VDT screen, and hearing and speech to communicate effectively in person and over the telephone. Strength and agility to exert up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. May work shifts and weekends. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this classification.