This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Auditor Clinical Validation (Place of Service, Short Stay & Readmission) based in the United States.
This role plays a critical part in ensuring the accuracy, integrity, and compliance of healthcare claims through detailed retrospective clinical audits. You will review medical records to evaluate place of service determinations, short-stay cases, and readmissions using nationally recognized clinical guidelines and evidence-based methodologies. The position requires strong clinical judgment, analytical precision, and the ability to interpret complex patient charts within proprietary auditing systems. You will be responsible for documenting clear rationales and supporting evidence for each audit decision while maintaining high standards of accuracy and productivity. Working in a structured remote environment, you will collaborate within audit operations to identify trends, improve processes, and support recovery opportunities. This is an impactful role for a clinically experienced professional who thrives in data-driven, detail-oriented review work and values quality, compliance, and continuous improvement.
Accountabilities:
- Conduct retrospective clinical chart reviews focused on readmission cases and place-of-service determinations using established clinical guidelines and audit methodologies.
- Analyze medical records to assess severity of illness, intensity of service, and appropriateness of care settings with strong clinical judgment and objectivity.
- Utilize proprietary audit systems and tools to perform claim evaluations, document findings, and generate audit letters with accuracy and consistency.
- Maintain productivity levels and meet or exceed established operational performance standards for audit volume, quality, and timeliness.
- Ensure high standards of accuracy in identifying valid claims, documenting rationales, and supporting audit conclusions with appropriate clinical references.
- Identify potential additional recovery opportunities outside assigned audit scopes and contribute insights for process and concept improvements.
- Collaborate with audit operations teams to support continuous improvement of tools, workflows, and methodologies.
- Complete assigned responsibilities, performance objectives, and special projects within required timelines and quality expectations.
Requirements
- Associate or Bachelor’s degree in Nursing required.
- Active, unrestricted Registered Nurse (RN) license in the state of residence.
- 5–7+ years of experience in Utilization Management and/or Case Management.
- Strong experience working with InterQual and/or MCG criteria (inpatient vs. observation status determination).
- Clinical background in acute care settings such as ICU, Emergency Department, Cath Lab, or Med-Surg.
- Case Management Certification preferred.
- Strong proficiency in Microsoft Office tools including Word, Excel, Access, and Teams.
- Excellent analytical skills with the ability to apply clinical guidelines and interpret complex medical documentation.
- Strong written and verbal communication skills, particularly in documenting audit rationale and findings.
- High attention to detail with the ability to assess accuracy, completeness, and consistency in clinical reviews.
- Ability to work independently in a structured remote environment with a dedicated and secure workspace.
- Comfort performing repetitive, detail-intensive analytical tasks requiring sustained concentration.
Benefits
- Competitive hourly compensation of $45.67/hour (approximately $95,000 annualized).
- Eligibility for discretionary bonus based on performance.
- Comprehensive medical, dental, vision, life, and disability insurance coverage.
- 401(k) retirement savings plan.
- Paid time off ranging from 17–27 days annually, depending on tenure and level.
- Nine paid company holidays per year.
- Paid family leave benefits.
- Fully remote work arrangement with structured training and onboarding.
- Stable full-time schedule with defined working hours during training (9 AM–5:30 PM ET).
- Opportunity to contribute to high-impact healthcare audit and compliance initiatives.