State Licensed Senior Auditor

Key responsibilities: Reviews appealed outpatient and specialty claims using medical coding principles and client-specific guidelines Constructs factual, reference-supported written responses to providers regarding appeal determinations Tracks MAC decisions and trends, preparing documentation for escalations and communications with stakeholders

Required qualifications: Associate's or Bachelor's degree in Nursing with an active/unrestricted license Outpatient Coding Credential (CCS, CCS-P, or CPC) required; eligible candidates must obtain certification within six months of employment Five or more years of related healthcare and auditing experience, particularly with SNF, IRF, Home Health, DME, and Hospice claims Proficiency in Word, Access, Excel, and other business applications Strong knowledge of Medicare coverage policies, medical necessity guidelines, and appeals regulations