Senior Clinical Auditor - Healthcare

Company Overview:

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our team is committed to innovation and excellence, making a significant impact in the insurance industry. If you’re ready to grow with the best, explore a career with us and make a difference.

Allied Universal® is hiring a Senior Clinical Auditor - Healthcare. The Senior Clinical Auditor is responsible for conducting complex chart reviews to identify inappropriate billing practices and ensure integrity of the documentation compliance. The Senior Clinical Auditor will have oversight in the review process of complex medical files during an investigation. The Auditor plans and implements process improvements within the re-evaluation process and review and is actively involved in strategic development of policy, system audits, and quality improvement planning.

RESPONSIBILITIES:

• Promote and oversee the review and audit process for chart/coding reviews for complex records
• Retrospective review of medical records to identify potential fraud, waste, and/or abuse and inappropriate billing practices
• Investigate, analyze, and identify provider billing practices to recommend payment based on medical records, claim history, billing codes, and policies
• Prepare detailed summary of findings and recommend next steps for escalated files assigned to investigators
• Ensure integrity of the record review and audit processes while providing improvement recommendations to management
• Work closely with internal departments, law enforcement and clients as necessary during the investigation process
• Ensure that all investigations adhere to company policies, industry standards, and legal requirements during the investigator
• Maintain accurate and organized records of all investigative activities and findings including but not limited to Special Investigations Unit (SIU) audit result letters

QUALIFICATIONS (MUST HAVE):

• Must possess one of the following:
• Bachelor’s degree in Nursing or related field of study
• Associate’s Degree in Nursing or related field of study with a minimum of five (5) years of practical experience in nursing, quality management or clinical auditing
• Current/active and Ongoing licensure as Registered Nurse (RN) or Licensed Practical Nurse (LPN)
• Must be able to obtain government security license
• Minimum of three (3) years of practical experience in nursing, quality management, or clinical auditing
• Minimum of three (3) years of experience in clinical coding, auditing, documentation improvement, or billing/coding compliance focusing on Managed Care and/or Medicare and Medical Services (CMS) programs
• Proficiency in Microsoft Office
• Ability to remain highly productive, strong attention to detail, with strong organizational skills
• Effective oral and written communication skills
• Able to follow instructions with integrity and maintain sensitive information with utmost discretion

PREFERRED QUALIFICATIONS (NICE TO HAVE):

• Knowledge of Managed Care and the Medicaid and Medicare programs
• Certified Clinical Documentation Specialist (CCDS)
• Certified Documentation Improvement Practitioner (CDIP)

BENEFITS:

• Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
• Seven paid holidays annually, sick days available where required by law
• Vacation time offered at an initial accrual rate of 3.08 hours biweekly; unused vacation is only paid out where required by law

Allied Universal® is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have difficulty using the online system and require an alternate method to apply or require an accommodation, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices.