A Nurse Auditor is responsible for reviewing medical records and to determine if the documentation substantiates the quality of care, medical necessity, utilization, and coding of insurance claims. Typical work activities listed on the Nurse Auditor Resume are – reviewing remittance advice for denials and the appeal process; ensuring optimal billing methods meet the billing compliance standards; inspecting the organization’s accounts, billing procedures, and medical records; finding out overcharged bills, preparing audit reports, details of the discrepancy and relevant recommendations for improvements; and ensuring all records are filed properly.
Key skills that can highlight a resume include the following – competent knowledge in the field of accounting, finance, and auditing; familiarity with common medical terminologies, treatments, tests, and concepts; the ability to sort, compile and extract voluminous data; and strong leadership skills. To enter this occupation, a nursing degree and knowledge of CPT, ICD9-CM, and HCPCS are considered mandatory.
Objective : Energetic Nurse Auditor, successful in case investigation, case management, implementation of the new policy, and/or edits and audits to prevent fraud waste and abuse; with a background in Successful staff supervision and improving staff morale by promoting team achievements.
Skills : Recruiting, Administration, Managing.
Description :
Reviewed all Trailblazers, CMS, OIG, correspondence, and adheres to all guidelines.
Performed assigned audits by researching documentation, analyzing information, and makes recommendations to improve the flow of claims and enters all corrections into the systems.
Stayed abreast of regulatory requirements and company compliance policies, payer requirements, significant changes and developments to ensure quality review measurements are in place at the facility.
Performed daily QA on all surgical accounts to ensure timely and accurate charging and appropriate clinical documentation to support charging.
Identified and worked with management to implement process improvements to lower costs and improve services to facility customers.
Adhered to all compliance guidelines and maintained the strictest confidentiality.
Supported by the compliance program set forth by Steward Health Care as demonstrated.
Experience
2-5 Years
Level
Executive
Education
BS In Nursing
Nurse Auditor Resume
Objective : As a Nurse Auditor, responsible for Performing daily QA on all surgical accounts to ensure timely and accurate charging and appropriate clinical documentation to support charging.
Skills : ED Nursing, Mental Health, Med/Surg Nursing, Administration, OR Nursing.
Description :
Audited of records for third party and patient requested audits.
Worked and maintained tools related to revenue integrity.
Evaluated and assisted with denial appeals.
Supervised the chargemaster liaison and utilization review staff.
Obtained DRG authorizations from insurance carriers.
Provided education to hospital departments/staff and physicians regarding rules and compliance with private insurance carriers, Medicare, and Medicaid services.
Assisted Director of Resource Management Supervision of case managers in absence of Director.
Experience
2-5 Years
Level
Executive
Education
Certification In Teaching
Nurse Auditor Resume
Objective : Seeking a Nurse Auditor position with an outstanding career opportunity that will offer a rewarding work environment along with winning teamwork.
Skills : Attention To Detail, Communication, Planning.
Description :
Performed comprehensive audits along with clinical record reviews to ensure documentation provides evidence of compliance with coverage requirements, physician's orders, care delivery standards, company policy, and regulatory requirements.
Communicated any reportable findings or issues identified during the audit process to Compliance/Coder Manager and Clinical Manager.
Provided education to members of the patient care team regarding specific documentation issues identified through concurrent and retrospective documentation reviews.
Participated in a corrective action plan process related to audit findings.
Provided feedback recommendations, revisions, or modifications to company policies.
Participated in clinical case conferences to assess patient progress, identify any clinical issues, and make changes to patient plan of care when indicated.
Provided training/mentoring to employees on the auditing process and OASIS coding.
Experience
2-5 Years
Level
Executive
Education
BS In Nursing
Nurse Auditor Resume
Objective : As a Nurse Auditor, responsible for Providing peer review of those responsible for the delivery and management of clinical care quality. and also Auditing all clinical areas to determine the extent of compliance with accreditation and licensure requirements (JCAHO, AHCA, etc).
Skills : Communication, Nursing, Collaborating.
Description :
Worked daily Observation reports to identify and correct Observation start and stop time errors.
Informed Nursing Department Leadership daily regarding errors in an effort to have the nurses correct their errors and to educate nursing staff.
Worked ED/Observation Infusion and Injection Report.
Corrected and added Infusion Injection charges entered by coding and added all Infusion/Injection charges for Observation stays in compliance with CMS rules and regulations.
Reviewed and resolved business office requests to correct edits.
Worked on the CCA Edit Program.
Collaborated with other Memorial Hermann vendors.
Experience
2-5 Years
Level
Executive
Education
BS In Nursing
Nurse Auditor Resume
Headline : To obtain a Nurse Auditor with 5 years of experience in Identifying if a discrepancy exists and document the findings using standard documentation guidelines applicable to the program.
Skills : Licensed Insurance Agent, Certified Senior Advisor, Certified In Long Term Care, Life Underwriting Training Council Fellow.
Description :
Reviewed medical bills for insurance carriers to validate billing with documentation accuracy.
Served as a professional role model for staff in areas of customer service, collaboration, communication, excellence, dress, attendance, and general professionalism.
Hand-selected phlebotomists, traveling doctors, and medical professionals to complete medical exams on life insurance applicants.
Created and implemented effective training and in-service programs.
Communicated with carrier underwriters to utilize and gain improved performance enhancing company relationships.
Maintained timekeeping records for the resource management department.
Ordered and maintained supplies for the resource management department.
Experience
5-7 Years
Level
Executive
Education
GED
Nurse Auditor Resume
Headline : As a Nurse Auditor, responsible for Reporting any problems in the audit process to the Manager for resolution. and also Complying with HIPAA and other regulations regarding the confidentiality of patient information.
Assessed patient bills for errors and correct them prior to submission to the insurance companies.
Identified $1.7 million in savings for the hospital.
Worked with various department directors to identify and correct discrepancies.
Handled questions by parents and patients concerning their bills and make appropriate corrections if warranted.
Performed side-by-side defense audits of patient bills with insurance company representatives.
Reported to Quality Assurance any legally liable documentation found during audits.
Conducted in-service training of hospital staff on the importance and correct manner in which to document in order to ensure more accurate billing.
Experience
5-7 Years
Level
Junior
Education
BS In Nursing
Nurse Auditor Resume
Objective : Nurse Auditor with 4 years of experience in Analyzing and resolving patient claims being held by billing edits that require clinical expertise.
Skills : LPN, Medical Coder, Nurse Chart Auditor/Reviewer.
Description :
Responsible for performing clinical, concurrent, requested, and defense audits.
Reviewed the MSC, and DET web tools, Bill 49 report, Late Charge Report, and Batch Report for billing compliance.
Reviewed the clinical aspects of denial logs.
Documented the appropriate actions in the collection system, assisted the IS manager in the review and maintenance of the ChargeMaster Files.
Analyzed charging procedures.
Problem solved with departments to help reduce unbilled items and errors in charging, made recommendations regarding charging and documentation procedure changes.
Performed patient complaint audits.
Experience
2-5 Years
Level
Executive
Education
G.E.D
Nurse Auditor Resume
Objective : Seeking a Nurse Auditor with 5+ years of experience in Identifying all coding, clinical, and charging documentation issues and assisting Facility departments to resolve issues.
Skills : Injections, Educator, Training & Development, Nursing.
Description :
Examined medical records to ensure that patient bills were correct and made sure that insurance claims complied with government regulations.
Reviewed retrospective medical records of denied services for medical necessity.
Ensured that appeals and grievances are resolved timely to meet regulatory timeframes.
Documented and logged appeal information on relevant tracking systems and mainframe systems.
Generated written correspondence to providers, members, and regulatory entities.
Utilized InterQual criteria for inpatient observation admission.
Worked with McKesson to review and correct identified Medicare Compliance Audit issues.
Experience
2-5 Years
Level
Executive
Education
High School Diploma
Nurse Auditor Resume
Objective : As a Nurse Auditor, Responsible for conducting a concurrent, retrospective, and insurance defense hospital bill audits for client hospitals Functioned as hospitals'.
Skills : IV Therapy, EKG, Injections, Emr, Prior Authorizations, E Prescribe/phone/fax Medications, Patient Education, Patient Scheduling.
Description :
Performed charge audits for Trinity Medical Center.
Audited patient's invoice to assure accuracy with all chargeable items and services that were provided during a hospital visit.
Completed ER disputes and special requests.
Performed OIG and IDA Audits.
Held monthly Audit meetings for CFO, Business office manager, and the Department Directors in which the Audit was performed to review problem areas and develop action plans to address nonconformities.
Entailed the concurrent review of inpatient and outpatient medical records and billing, documentation education for management staff, and insurance defense audits with outside insurance auditors.
Used Microsoft Excel, Access, Word, and PowerPoint as part of daily routine.
Experience
2-5 Years
Level
Junior
Education
Associate In Nursing
Nurse Auditor Resume
Summary : Nursing experience including 16 years in the Healthcare of Adults, Women, Newborns, Pediatrics, and Injured Workers. Educating, teaching, and instructing clients about disease processes and self-care. Strong interpersonal skills with the ability to quickly establish a working rapport. Ability to build positive relationships with clients, physicians, and fellow health care professionals to promote successful client outcomes and company savings.
Skills : Leadership Development, Coding, Nursing.
Description :
Worked closely with the hospital Compliance Officer completing compliance audits at physician practices and documentation of compliance issues within the network.
Analyzed and resolved patient claims being held by billing edits that would be the responsibility of RI on the Failed claims, Failed bill, Issues, Rebill, HIM and Unbilled logs, Correct Coding Initiative, Self-Administered and other claims requiring clinical and hospital business office expertise.
Interacted with ancillary departments to obtain additional information needed to properly bill account based on documentation in the medical record.
Identified charging, coding, or clinical documentation issues and works with ancillary departments to resolve issues and notify appropriate leadership.
Reviewed all Trailblazers, CMS, OIG, correspondence, and adhered to all guidelines.
Performed, assigned audits by researching documentation, analyzing information, and makes recommendations to improve the flow of claims and enters all corrections into the systems.
Stayed abreast of regulatory requirements and company compliance policies, payer requirements, significant changes, and developments to ensure quality review measurements are in place at the facility.
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