Healthcare Audit Policy Analyst (Registered Nurse or Medical Coder)

Training and Documentation

• Contribute to the creation of training materials, job aids, and reference tools for both new and existing audit concepts.
• Maintain organized, accessible documentation of audit policies and concept updates.

Cross-Functional Collaboration and Client Support

• Respond to client inquiries and provide subject matter support to client services for presentations and escalations.
• Partner with operations, clinical teams, technology, and internal stakeholders to support policy execution and drive concept quality.
• Provide expert feedback to improve policy usability, accuracy, and effectiveness across the organization.

Performance Monitoring and Analytics

• Monitor concept performance and provide statistical analysis to drive scoring and selection for new and existing audit concepts.
• Identify trends in concept performance data and make recommendations to optimize audit yield and accuracy.
• Stay informed of payment integrity policy developments, coding updates, and industry trends.

Process Improvement

• Identify opportunities to improve audit concept workflows, documentation processes, and policy management practices.
• Support ongoing enhancements to concept tracking, QA processes, and cross-functional coordination.

Other Duties

• Perform additional responsibilities and ad hoc projects as assigned to meet business needs.

What You Bring

Education and Experience

• Bachelor's degree in health administration, business, nursing, or a related field, or equivalent experience.
• Minimum 5+ years of progressive experience in healthcare claim type subject matter specialty, including direct experience in payment integrity and claims auditing.
• Equivalent experience of 3+ years in claims auditing and recovery auditing.
• Registered Nurse or Certified Coder holding a nationally recognized credential (RHIA, RHIT, AHIMA, AAPC, or equivalent) required.

Knowledge, Skills, and Expertise

• Demonstrated depth and breadth of knowledge across payment integrity elements, including: ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and HIPPS coding systems and MS-DRG, APR-DRG, APC, APG, PDPM, and PDGM payment methodologies.
• Deep understanding of Medicare and Commercial coding rules, regulations, and prospective payment systems.
• Superior knowledge of healthcare coding, billing, reimbursement, and claim adjudication standards and procedures.
• Broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
• Expert knowledge of clinical criteria documentation requirements and audit concept development across claim types.
• Strong experience in data utilization and statistical analysis, including driving scoring and selection for audit concepts.
• Progressive healthcare data analysis experience, including gathering and documenting requirements for projects of diverse scope and complexity.
• Experience developing clinical content, policy documentation, and training resources.
• Proven ability to communicate effectively with all levels of the organization, with diverse teams, and with external clients.
• Exceptional written and verbal communication skills with strong attention to detail.
• Excellent critical thinking and analytical skills.
• Demonstrated ability to manage multiple concurrent workflows independently and in a remote environment, delivering results on time.

Computer Equipment and Software

• Proficient in Windows office systems, including the full Microsoft Suite (Excel, Word, Outlook, PowerPoint, SharePoint, and Teams).
• Advanced skills in Microsoft Office, particularly Excel and PowerPoint.
• Familiarity with multiple encoder/grouper applications.
• Experience working with various software platforms and collaborating with development teams.
• Proven success in a remote working environment.

Pay Range: $80,000 - $120,000

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