State Licensed Senior Auditor
Job Summary
To support the appeals process for skilled nursing and other healthcare claims, the full-time State Licensed Senior Auditor will independently review and interpret medical records, apply coding principles, and construct well-supported written responses while utilizing AI tools to enhance efficiency and quality.
Key responsibilities
- Reviews appealed outpatient and specialty claims using medical coding principles and client-specific guidelines
- Constructs factual, reference-supported written responses to providers regarding appeal determinations
- Tracks MAC decisions and trends, preparing documentation for escalations and communications with stakeholders
Required qualifications
- Associate's or Bachelor's degree in Nursing with an active/unrestricted license
- Outpatient Coding Credential (CCS, CCS-P, or CPC) required; eligible candidates must obtain certification within six months of employment
- Five or more years of related healthcare and auditing experience, particularly with SNF, IRF, Home Health, DME, and Hospice claims
- Proficiency in Word, Access, Excel, and other business applications
- Strong knowledge of Medicare coverage policies, medical necessity guidelines, and appeals regulations
Complete Job Description
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