Clinical Pre-Service Nurse Auditor
Location
United States
Posted
3 days ago
Salary
Not specified
No structured requirement data.
Job Description
SUMMARY: The Clinical Pre-Service Nurse Auditor is responsible for applying clinical judgment, utilization management principles, and payer-specific guidelines to prevent denials and support efficient, compliant patient care. The Auditor reviews upcoming procedures and scheduled cases to verify that all insurance and medical necessity requirements are met prior to services being performed. Additionally, the Auditor secures payer authorizations, confirms that clinical documentation supports medical necessity, and identifies cases that may require rescheduling or additional review.
- Reviews scheduled procedures and outpatient services to confirm payer authorization requirements are met.
- Obtains authorizations or pre-certifications according to payer-specific criteria and documentation standards.
- Evaluates medical documentation to ensure medical necessity and compliance with nationally recognized guidelines (e.g., InterQual, Milliman).
- Communicates with physicians, clinical staff, and scheduling teams when additional information or action is required before the procedure.
- Identifies cases that may require rescheduling or adjustment based on payer criteria or authorization status.
- Maintains a current understanding of payer policies, provider contracts, and authorization protocols.
- Compiles and updates payer reference materials and communicates process updates to relevant departments.
- Collaborates with clinical and administrative teams to support timely, accurate, and compliant authorization workflows.
- Perform other related tasks as needed.
- Strong understanding of payer requirements, authorization processes, and utilization management principles.
- Working knowledge of hospital coding, billing, and documentation standards.
- Proficient in using payer portals, EMR systems, and authorization management tools.
- Knowledge of InterQual and Milliman criteria and Medicare guidelines.
- Excellent critical-thinking, problem-solving, and analytical skills.
- Strong written and verbal communication skills; able to work effectively with physicians and multidisciplinary teams.
- Strong attention to detail and ability to manage multiple cases in a fast-paced environment.
- Ability to interact successfully in a culturally diverse setting.
- Licensed Vocational Nurse (LVN) in the State of Texas
- Three (3) years of hospital experience in various clinical areas
- One (1) year utilization review, authorization, or case management experience
- 3 Medical Plans
- 2 Dental Plans
- 2 Vision Plans
- Employee Assistant Program
- Short- and Long-Term Disability Insurance
- Accidental Death & Dismemberment Plan
- 401(k) with a 2-year vesting
- PTO + Holidays
Please visit our website for more information:
Compensation to be determined by the education, experience, knowledge, skills, and abilities of the applicant, internal equity, and alignment with market data.
Employment for this position is contingent upon the successful completion of a background check and drug screening.
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