Clinical Appeal Revenue Integrity Nurse Auditor

About the role

CentraState Healthcare System seeks a Clinical Appeal Revenue Integrity Nurse Auditor to ensure clinical documentation meets medical necessity standards and to manage appeal processes for denied services. The role bridges clinical, coding, billing, compliance, and finance teams to improve revenue cycle performance.

Key responsibilities

• Review clinical denials, identify root causes, and write fact‑based appeal letters.
• Conduct prospective and retrospective audits of coding, billing, and documentation.
• Track denial patterns, analyze trends, and develop action plans to reduce denials.
• Ensure compliance with Medicare, Medicaid, commercial payer guidelines, and federal/state regulations.
• Collaborate with physicians, nurses, CDI, and coding teams on documentation improvement and correct code assignment.
• Prepare reports and dashboards on audit findings, denials, and compliance metrics.
• Provide education and presentations on denial prevention across the hospital.

Required profile

• Experience auditing clinical documentation and handling appeal letters.
• Knowledge of Medicare, Medicaid, and commercial payer requirements.
• Familiarity with ICD‑10, CPT, and charge coding processes.
• Ability to analyze data, identify revenue integrity risks, and recommend process improvements.
• Strong written communication skills for concise, fact‑based appeals.

Required skills

• ICD‑10 coding
• CPT coding
• Data analysis
• Report/dashboard creation

What we offer

• Opportunity to work within a leading nonprofit health system.
• Collaboration with multidisciplinary teams focused on revenue cycle excellence.
• Professional development through national organization participation.