Nurse Review Auditor (REMOTE)
Franklin, TN && United States - Remote
Full-Time
Mid (3-6 yrs)
Finance & Accounting
Posted on March 19, 2026
Key Responsibilities
Review, analyze, and resolve high-complexity claims and denials requiring advanced clinical judgment, payer-specific interpretation, and regulatory expertise.
Determine appropriate admission type, level of care, length of stay, care setting, and coverage based on clinical documentation and payer-specific rules.
Apply appropriate medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG, LCD/NCD, and payer-specific policies).
Perform line-item reviews to validate accuracy, compliance, and reimbursement integrity.
Review DRG assignments and downgrades and identify opportunities for support, correction, or appeal.
Document clear, concise opinions, conclusions, and recommendations supported by clinical evidence.
Compose high-quality clinical appeals with supporting documentation from nationally recognized sources (e.g., CMS, peer-reviewed literature, InterQual/MCG, specialty society guidance, etc.).
Identify trends, risks, and educational opportunities across audit findings.
Communicate results and insights to internal leadership and external partners in a professional and actionable manner.
Support continuous improvement efforts through data-driven recommendations and collaboration with operational teams.
Provide guidance and clinical insight to support alignment, knowledge-sharing, and quality outcomes across global operations.
Collaborate with domestic and international teams to ensure consistency in medical review standards, audit methodology, and best practices.
Communicate audit findings, clinical rationale, and recommendations clearly and professional across a globally distributed workforce.
Requirements and Qualifications
Active RN license with ADN or BSN required. Compact State licensure preferred.
Minimum of 2 years’ experience in:
Prerequisites
General computer skills (including use of Microsoft Office, specifically Excel and Outlook, internet search).
Strong verbal, written and interpersonal communication skills.
Ability to think critically and make decisions within individual role and responsibility.
Strong organizational and time management skills with the ability to manage workload independently.
Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).
Proven knowledge of trauma/medical/surgical procedures, clinical treatment patterns and healthcare practices and trends
Strong clinical assessment and critical thinking skills.
Familiarity with health care documentation systems.
Ability to interpret policies and procedures and communicate complex topics to others.
Ability to communicate audit outcomes and clinical appeal strategies with other staff within the company who are both medically and non-medically oriented.
Special Considerations
Professional Coding Credentials: AAPC and/or AHIMA certification (e.g., CPC, CCS, RHIA, RHIT) reflecting advanced understanding of coding standards and regulatory requirements is a plus
Technology Proficiency: Demonstrated familiarity with EMR/EHR systems and the ability to efficiently navigate electronic medical records across multiple platforms
Audience-Adaptive Communication: Ability to clearly articulate audit outcomes, clinical rationale, and recommendations to both medically trained professionals and non-clinical audiences, ensuring understanding, alignment, and actionable next steps
- Medical Necessity Reviews
- Admission/Length of Stay
- LCD/NCD interpretation and application
- DRG validation and downgrade reviews
- Line-item reviews
- 3-5 years’ acute care hospital experience in one of more of the following:
- ICU/Trauma
- Surgery
- Orthopedics
- Neurosurgery
- Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
- Elevated level of analytical ability and attention to detail
- Excellent written and verbal communication skills
Company: EnableComp
Provides revenue cycle management in healthcare and complex claims resolution, revolutionizing these areas for healthcare providers to ensure maximum rightful revenue.
501-1000 employees
Healthcare & Life Sciences
HQ: United States
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