Nurse Auditor

Key Responsibilities

Charge Audit & Billing Validation (Primary Focus)

• Perform comprehensive charge audits for inpatient and outpatient services.
• Review itemized billing statements against medical records to verify accuracy and completeness.
• Identify and document: missing charges, duplicate charges, unsupported or non-compliant charges.
• Validate charges based on clinical documentation, coding rules, and billing guidelines.
• Ensure all billing aligns with CMS and payer requirements, national healthcare billing audit guidelines, and organizational compliance standards.
• Submit clear, actionable audit findings to revenue cycle teams for correction and rebilling.

Audit Analysis & Documentation

• Analyze audit findings to determine root causes and patterns.
• Maintain accurate audit documentation that is clear, traceable, and defensible.
• Track audit outcomes and financial impact.
• Assist in developing recommendations to improve charge capture accuracy and billing processes.

Collaboration & Education

• Partner with coding and billing teams, clinical departments, and revenue cycle leadership.
• Provide guidance on documentation requirements, charge capture practices, and billing compliance standards.
• Support education efforts to prevent recurring audit issues.

Required Qualifications

• Active Registered Nurse (RN) license or LPN license.
• 5+ years of clinical nursing experience (ICU, ED, OR, or acute care preferred).
• Experience performing charge audits, chart reviews, and billing validation.
• Strong understanding of medical record documentation and hospital billing processes.

Technical Knowledge & Skills

• Knowledge of CPT, HCPCS, ICD-10 coding basics, revenue codes and charge capture processes, and inpatient and outpatient billing rules.
• Familiarity with Medicare, Medicaid, and commercial payer billing guidelines, CMS regulations and compliance expectations.
• Ability to interpret itemized bills, clinical documentation, and diagnostic reports, and identify discrepancies and determine correct billing practices.
• Experience using EHR systems (Epic, Cerner, Meditech) and audit or billing tools/data systems.

Core Competencies

• Strong analytical and critical thinking skills.
• High attention to detail and accuracy.
• Ability to work independently and manage priorities.
• Clear and professional written and verbal communication.
• Ability to translate complex findings into actionable insights.

Preferred Experience

• Prior experience in revenue integrity or healthcare auditing, denials or utilization review.
• Familiarity with DRG concepts (MS-DR).