SIU Nurse Auditor, RN, CPC

Job Description:
• Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
• Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
• Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
• Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
• Support fraud investigators with medical review expertise to detect and address fraudulent activities.
• Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Requirements:
• Minimum **Associate’s Degree in Nursing** required;
• Current, unrestricted **Registered Nurse (RN)** license in applicable state(s).
• Certification in medical coding from **AAPC** or **AHIMA** (e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
• Minimum **5 years of clinical nursing experience**, preferably with exposure to hospital bill auditing or defense auditing.
• Strong knowledge of **provider manuals**, **reimbursement policies**, and **medical policy guidelines**.
• Prior experience with **healthcare fraud investigation** and auditing is highly preferred.
• Proficiency in CPT/HCPCS and ICD-10 coding, with a strong foundation in auditing, accounting, and control principles.
• Analytical and problem-solving skills with a keen attention to detail.
• Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
• Strong proficiency in Microsoft Office and familiarity with audit tracking systems.

Benefits: