Clinical Auditor - RN
Description We are seeking a detail-oriented Clinical Auditor Registered Nurse to support medical record reviews, billing compliance audits for the Indiana Health Coverage 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 occasional travel required within Indiana.
Key Responsibilities
- Review medical records and related documentation to evaluate provider compliance with Indiana Health Coverage 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 Indiana Medicaid program and policy updates.
- Research Indiana 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.
Requirements
- RN license preferred; Indiana license or compact license accepted.
- Coding certification such as CCS or CPC strongly preferred.
- Candidate located in or near the Indianapolis area is preferred.
- At least 1 year of Medicaid claims review, billing compliance, or healthcare reimbursement experience.
- Familiarity with Indiana 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.
Physical Requirements & Environmental Conditions: An employee must meet these physical demands to successfully perform the essential functions of this job. Employee is regularly required to talk or hear, sit, and utilize technology tools such as a laptop computer for extended periods of time. Specific vision abilities include close vision and the ability to adjust focus. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Briljent is a solutions-based company. Solutions come from creative ideas; ideas come from being creative with differences. Briljent believes diversity and inclusion are critical to the success of the company. Employment at Briljent is based on merit and professional qualifications. We do not discriminate against any employee or applicant because of race, creed, color, religion, gender, sexual orientation, national origin, disability, age, veteran status, marital status or any other basis protected by federal, state or local law, regulation or ordinance.