Senior Clinical Auditor
On-siteDallas, Texas, United States
Job Summary
Conduct complex chart reviews to identify inappropriate billing practices, fraud, waste, and abuse while overseeing the audit process for medical records. Investigate provider billing practices against policies and claim history to recommend payment, preparing detailed summaries for escalated files. Implement process improvements within the re-evaluation workflow and ensure all investigations adhere to legal requirements and industry standards. Maintain accurate records of investigative activities and collaborate with internal departments and law enforcement as necessary. Requires RN or LPN licensure with a minimum of five years of clinical auditing experience and three years in clinical coding or documentation improvement.
Required Qualifications
- Bachelor's degree in Nursing or related field of study
- Associate's Degree in Nursing or related field of study with a minimum of five (5) years of practical experience in nursing, quality management or clinical auditing
- Current/active and Ongoing licensure as Registered Nurse (RN) or Licensed Practical Nurse (LPN)
- Must be able to obtain government security license
- Minimum of three (3) years of practical experience in nursing, quality management, or clinical auditing
- Minimum of three (3) years of experience in clinical coding, auditing, documentation improvement, or billing/coding compliance focusing on Managed Care and/or Medicare and Medical Services (CMS) programs
- Proficiency in Microsoft Office
- Ability to remain highly productive, strong attention to detail, with strong organizational skills
- Effective oral and written communication skills
- Able to follow instructions with integrity and maintain sensitive information with utmost discretion
Desired Qualifications
- Knowledge of Managed Care and the Medicaid and Medicare programs
- Certified Clinical Documentation Specialist (CCDS)
- Certified Documentation Improvement Practitioner (CDIP)
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