franklin Work Opportunities ∙ Page 1

462 Remote & work from home jobs online

Nurse Review Auditor (REMOTE)

Enablecomp · Franklin, United States Of America · Remote

Apply Now

Description

EnableComp provides Specialty Revenue Cycle Management solutions for healthcare organizations, leveraging over 24 years of industry-leading expertise and its unified E360 RCM™ intelligent automation platform to improve financial sustainability for hospitals, health systems, and ambulatory surgery centers (ASCs) nationwide. Powered by proprietary algorithms, iterative intelligence from 10M+ processed claims, and expert human-in-the-loop integration, EnableComp provides solutions across the revenue lifecycle for Veterans Administration, Workers’ Compensation, Motor Vehicle Accidents, and Out-of-State Medicaid claims as well as denials for all payer classes. By partnering with clients to supercharge the reimbursement process, EnableComp removes the burden of payment from patients and provider organizations while enabling accelerated cash, higher and more accurate yield, clean AR management, reduced denials, and data-rich performance management. EnableComp is a multi-year recipient the Top Workplaces award and was recognized as Black Book's #1 Specialty Revenue Cycle Management Solution provider in 2024 and is among the top one percent of companies to make the Inc. 5000 list of the fastest-growing private companies in the United States for the last eleven years. 
 

Position Summary

The Clinical Nurse Auditor is responsible for performing comprehensive clinical audits to ensure medical necessity, regulatory compliance, and payer guideline adherence across a broad portfolio of high-complexity claims. This role applies expert clinical judgment to evaluate medical services, admission status, level of care, and coverage determinations for claims involving non-standard benefits, jurisdictional variances, and specialized regulatory frameworks. The Clinical Nurse Auditor partners with internal and external stakeholders to identify trends, mitigate risk, and support accurate reimbursement through accurate documentation and well-supported clinical appeals.

Key Responsibilities

  • Review, analyze, and resolve high-complexity claims and denials requiring advanced clinical judgment, payer-specific interpretation, and regulatory expertise.
  • Determine appropriate admission type, level of care, length of stay, care setting, and coverage based on clinical documentation and payer-specific rules.
  • Apply appropriate medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG, LCD/NCD, and payer-specific policies).
  • Perform line-item reviews to validate accuracy, compliance, and reimbursement integrity.
  • Review DRG assignments and downgrades and identify opportunities for support, correction, or appeal.
  • Document clear, concise opinions, conclusions, and recommendations supported by clinical evidence.
  • Compose high-quality clinical appeals with supporting documentation from nationally recognized sources (e.g., CMS, peer-reviewed literature, InterQual/MCG, specialty society guidance, etc.).
  • Identify trends, risks, and educational opportunities across audit findings.
  • Communicate results and insights to internal leadership and external partners in a professional and actionable manner.
  • Support continuous improvement efforts through data-driven recommendations and collaboration with operational teams.
  • Provide guidance and clinical insight to support alignment, knowledge-sharing, and quality outcomes across global operations.
  • Collaborate with domestic and international teams to ensure consistency in medical review standards, audit methodology, and best practices.
  • Communicate audit findings, clinical rationale, and recommendations clearly and professional across a globally distributed workforce.

    • Requirements and Qualifications

  • Active RN license with ADN or BSN required. Compact State licensure preferred.
  • Minimum of 2 years’ experience in:
    • Medical Necessity Reviews
    • Admission/Length of Stay
    • LCD/NCD interpretation and application
    • DRG validation and downgrade reviews
    • Line-item reviews
    • 3-5 years’ acute care hospital experience in one of more of the following:
      • ICU/Trauma
      • Surgery
      • Orthopedics
      • Neurosurgery
      •  Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
      • Elevated level of analytical ability and attention to detail
      • Excellent written and verbal communication skills

    • Prerequisites

  • General computer skills (including use of Microsoft Office, specifically Excel and Outlook, internet search).
  • Strong verbal, written and interpersonal communication skills.
  • Ability to think critically and make decisions within individual role and responsibility.
  • Strong organizational and time management skills with the ability to manage workload independently.
  • Demonstrated competency in claim review and experience in using billing and claims forms (UB, CMS, and HCFA).
  • Proven knowledge of trauma/medical/surgical procedures, clinical treatment patterns and healthcare practices and trends
  • Strong clinical assessment and critical thinking skills.
  • Familiarity with health care documentation systems.
  • Ability to interpret policies and procedures and communicate complex topics to others.
  • Ability to communicate audit outcomes and clinical appeal strategies with other staff within the company who are both medically and non-medically oriented.

    • Special Considerations

  • Professional Coding Credentials: AAPC and/or AHIMA certification (e.g., CPC, CCS, RHIA, RHIT) reflecting advanced understanding of coding standards and regulatory requirements is a plus
  • Technology Proficiency: Demonstrated familiarity with EMR/EHR systems and the ability to efficiently navigate electronic medical records across multiple platforms
  • Audience-Adaptive Communication: Ability to clearly articulate audit outcomes, clinical rationale, and recommendations to both medically trained professionals and non-clinical audiences, ensuring understanding, alignment, and actionable next steps

    • Additional Information

    EnableComp is an Equal Opportunity Employer M/F/D/V. All applicants will be considered for this position based upon experience and knowledge, without regard to race, color, religion, national origin, sexual orientation, ancestry, marital, disabled or veteran status. We are committed to creating and maintaining a workforce environment that is free from any form of discrimination or harassment.
     
    EnableComp recruits, develops and retains the industry's top talent.  As the employer of choice in the complex claims industry, EnableComp takes pride in our continuous commitment to building and maintaining a culture centered around fostering the professional growth and development of our people.  We believe that investing in our employees is the key to our success, and we are dedicated to providing them with the tools, resources, and support they need to thrive and grow their career here. At EnableComp, we are committed to living up to our core values each and every day, and we believe that this commitment is what sets us apart from other companies.  If you are looking for a company that values its employees and is dedicated to helping them achieve their full potential, then EnableComp is the place for you.
     
     Don’t just take our word for it!  Hear what our people are saying:
    “I love my job because everyone shares the same vision and is determined and dedicated. People care about you as a person and your professional growth. There is a genuine spirit of cooperation and shared goals all revolving around helping each other.” – Revenue Specialist
     
    “I enjoy working for EnableComp because of the Core Values we believe in. EnableComp stands true to these values from empowering employees to ecstatic clients. This company is family oriented and flexible, along with understanding the balance of work, life, and fun.” – Supervisor, Operations