Nurse Review Auditor (REMOTE)

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.
• Stro