RegisteredNurse Clinical Auditor

We are seeking a detail-oriented Registered Nurse to support medical record reviews and

billing compliance audits for State Medicaid Programs. This role is responsible for evaluating

quality of care, reviewing medical records and program policies and identifying compliance

issues, preparing audit documentation and reports, and supporting appeals activities. The ideal

candidate brings clinical knowledge, regulatory awareness, and strong analytical and writing

skills. This is a remote position with potential for occasional travel.

Key Responsibilities

• Review medical records and related documentation to evaluate provider compliance with State Medicaid Programs, CMS, AMA, and other applicable standards and regulations.

• Conduct medical record and compliance reviews independently and provide preliminary findings to the Lead Reviewer.

• Identify potential documentation deficiencies, and billing compliance issues.

• Maintain detailed workpapers documenting procedures performed, records reviewed, findings identified, and conclusions reached.

• Assist with audit responses and appeals as needed.

• Ensure all work aligns with state, federal, and national healthcare and Medicaid guidelines.

• Stay current on clinical guidelines, policies, regulations, and Medicaid program and policy updates.

• Research Medicaid rules and maintain internal repositories of bulletins, policies, and procedures.

• Adapt quickly to changing priorities, policies, regulatory updates, and review requirements while maintaining accuracy and meeting deadlines.

Qualifications

• RN license preferred; Colorado license or compact license accepted.

• Coding certification such as CCS or CPC strongly preferred.

• Candidate located in or near the Denver area is preferred.

• At least 1 year of Medicaid claims review, billing compliance, or healthcare reimbursement experience.

• Familiarity with Medicaid policies, payer guidelines, and documentation requirements preferred.

• Knowledge of CPT coding guidelines and ICD-10 standards.

• Proficiency in Microsoft Excel, Word, and Outlook.

• Strong analytical, critical thinking, problem-solving, and technical writing skills.

• Ability to work independently and collaboratively in a fast-paced environment.

• Experience working with healthcare providers strongly preferred.

• Knowledge of healthcare claims data and fraud, waste, and abuse preferred.