State Licensed Senior Auditor

To support the appeals process for skilled nursing and other healthcare claims, the full-time State Licensed Senior Auditor will independently review and interpret medical records, apply coding principles, and construct well-supported written responses while utilizing AI tools to enhance efficiency and quality. 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