A nurse auditor is responsible for reviewing medical records to determine whether documentation substantiates the medical necessity, quality of care, utilization, and coding of insurance claims. A nurse auditor insures that data collection for reporting purposes from various departments is within charging practices and departmental policies. Duties include reviewing remittance advices for denials and the appeal process, and finalizing department audit summaries. A nurse auditor ensures optimal billing methods that meet with billing compliance standards (regulations).
A nurse auditor should have a LVN and/or RN degree in nursing. Experience of 2+ years in performing audits to ensure maximum achievable reimbursement is required for such positions. Knowledge of CPT, ICD9-CM, HCPCS or other coding structures are usually required. A nurse auditor well versed in commercial and government insurances may be at an advantage. Ability to communicate with all levels of management, such as nursing, ancillary, financial service staff, and outside parties is important.
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