Clinical Validation and Hospital Bill Auditor - Remote

Clinical Validation and Hospital Bill Auditor - Remote

Amenity Consulting, LLC is recruiting for a Clinical Validation and Hospital Bill Auditor. The Auditor is responsible for
1) performing clinical validation review for DRG and Level of Care audits,
2) performing hospital bill audits and itemized bill reviews, and
3) providing clinical subject matter expertise to support fraud, waste and abuse investigations. The Auditor is responsible for analyzing and auditing healthcare claims (facility, professional, and ancillary) and medical records to identify over charging/unbundling, medical necessity issues and inappropriate coding practices, including those related to clinical validation of diagnoses. The Auditor is responsible for researching, interpreting, and applying client‑specific coding/medical policies and provider‑specific contract provisions.

The ideal candidate will display strong initiative, be detail oriented and well organized, possess strong problem‑solving and communications skills, and be able to work independently, with minimal supervision.

• Reviewing and interpreting healthcare claims and medical records to identify medical necessity issues, clinical validation of diagnoses, and inappropriate charging practices, e.g., related to unbundling, upcoding, and investigational services.
• Supporting healthcare fraud and abuse investigations.
• Providing subject matter expertise to Amenity’s clients when requested.
• Drawing conclusions and making logical recommendations based on consideration of clinical review judgement, client preferences, unique circumstances, and client‑specific information, e.g., contract provisions, policies, and financial thresholds.
• Supporting audit findings by researching and documenting Amenity and industry‑standard rationale, e.g., revenue/ICD/HCPCS coding guidelines, state and federal statutes, and CMS regulations.
• Managing sensitive and confidential information.
• Effectively utilizing Amenity’s case tracking tools to prioritize, execute, document, and report audit activities.
• Meeting or exceeding Amenity’s audit‑related productivity and quality standards, e.g., hit rate, productivity, accuracy.
• Preparing written and verbal responses to provider disputes of audit findings.
• Identifying new or expanded auditing concepts and financial recovery opportunities.
• Recommending process improvements to enhance communications, operational efficiency, outcome reporting and client satisfaction.

• Registered Nurse (RN) with 5+ years experience in clinical nursing
• Prefer 2+ years’ experience in clinical validation.
• Prefer 2+ years in hospital bill auditing.
• Prefer experience in the health insurance/vendor/professional services space.
• Prefer 2+ years in case/utilization management.
• Proficiency in the use of Microsoft Office software, i.e., Outlook, Word, Excel, PowerPoint, and Access; ability to create charts, presentations, graphs, and spreadsheets.
• Strong clinical knowledge, i.e., of anatomy and physiology.
• Strong knowledge of medical necessity criteria, and coding terminology.
• Strong analytical skills and problem‑solving abilities.
• Strong interpersonal relationship skills.
• Experience working within the healthcare industry.
• Ability to manage multiple priorities and deadlines.
• Ability to work remotely (with minimal direction) as part of a multi‑disciplinary team.
• Knowledge of Medicare and Medicaid regulations.
• Exceptional written and verbal communication skills.
• Ability to ramp up quickly in a fast‑paced environment.
• Must be able to pass all pre‑employment screens (including background/criminal checks and post‑offer drug test) as requested.