We are looking for a Registered Nurse with a minimum of 3 years of clinical/hospital experience to join our US Healthcare team as a Clinical Auditor. The role involves reviewing and auditing claims against medical records, identifying findings based on billing, performing best practice reviews, identifying areas for improvement, and ensuring compliance with CMS guidelines.
Key Responsibilities
- Familiarity with basic medical terminology and concepts used in care management.
- Ability to effectively participate in a multi-disciplinary team including internal and external participants.
- Good understanding of the US healthcare system and care management.
- Perform audits based on clinical knowledge while reviewing medical records.
- Demonstrate learning agility during process training and career development.
- Perform quality assurance reviews to assess comprehension of training efforts.
- Process audits with accountability and accuracy.
- Review all documented system information and any additional records/data presented to support a determination or recommendation.
- Condense clinical information into a clear and precise clinical picture while making final decisions.
- Proactively enhance process knowledge and consistently deliver high-quality work.
- Stay updated on process changes and implement recent guidelines.
- Analyze errors and collaborate with the Quality team for clarification when required.
- Maintain a professional work environment.
- Follow all Standard Operating Procedures (SOPs) without exception.
- Complete assigned audits within quality standards.
- Achieve the expected quality and productivity targets.
- Follow all project-related protocols and instructions.
- Update productivity logs, clarification logs, and other applicable trackers daily.
- Maintain alignment with the Manager/Team Lead regarding program delivery.
- Respond promptly to emails.
- Ensure compliance with established process guidelines.
Qualifications
- Bachelor's Degree in Nursing.
- Active State Nursing Certification is mandatory.
- Minimum 3 years of clinical/hospital experience is mandatory.
- Strong written and verbal communication skills.
- Prior auditing experience is an added advantage.