Chart Auditor

Education and Work Experience:

• Associate's degree in Nursing or related clinical field: Required
• Bachelor's Degree in Nursing (BSN) or Healthcare Administration: Preferred
• Prior experience in utilization review, case management, coding, or clinical auditing: Preferred

Licenses/Certifications:

• Current licensed RN in the state of practice (RN), medical provider (MD), or International Medical Graduate with valid credential: Required
• Registered Nurse (RN) or Medical license MD (MD) or Foreign Medical Doctor (FMD): Required

Essential Functions:

• Conducts concurrent audits of active cases to identify documentation and order issues in real time, preventing downstream denials. Applies InterQual or Milliman/MCG criteria to validate patient status decisions and payer medical necessity compliance.
• Reviews medical records to validate patient placement (inpatient vs. observation) against payer criteria and physician orders. Audits clinical denials to determine root cause, trends, and opportunities for appeal, and recommends actionable prevention strategies. Performs charge audits and account reconciliations to ensure documentation is appropriate, compliant with regulations, and free of denial risk. Provides recommendations for charge corrections and technical assistance in staff training.
• Identifies barriers to clean claims and timely payment; tracks and trends denials, escalating systemic issues to the Director/Manager. Tracks and trends payer clinical denials, observation hours, and placement errors; prepares reports for Revenue Management leadership. Provides feedback to Coding and CDI teams regarding documentation needed for coding accuracy and DRG assignment.
• Partners with Case Management, Utilization Management, Medical Officer, and Physician Advisors to ensure accurate clinical documentation and timely status changes. Collaborates in payer escalations and appeal preparation by supplying clinical and documentation findings. Educates providers and staff on documentation, status order accuracy, and denial prevention strategies.
• Monitors CMS, state, and commercial payer regulatory changes impacting clinical documentation, placement, and observation requirements; integrates updates into audit practices. Demonstrates reliability, responsiveness, and effective follow-up on matters requiring attention.
• Performs other job-related duties as assigned.

Organizational Requirements:

Adventist Health is committed to the safety and wellbeing of our associates and patients. Therefore, we require that all associates receive all required vaccinations as a condition of employment and annually thereafter, where applicable. Medical and religious exemptions may apply.

Adventist Health participates in E-Verify. Visit https://adventisthealth.org/careers/everify/ for more information about E-Verify. By choosing to apply, you acknowledge that you have accessed and read the E-Verify Participation and Right to Work notices and understand the contents therein.