Clinical Appeals Nurse Auditor in Santa Fe Springs, CA at Avanti Hospitals

Date Posted: 11/5/2020

Job Snapshot

Job Description

Central Business Office

Job Title: Clinical Appeals Nurse Auditor  

City: Santa Fe Springs / State: California    

Central Business Office

Day Shift

From 9:00 AM

To 5:30 PM


Job Description and Job Responsibilites

Job Summary:  The Nurse auditor is responsible for day to day review, coordination and management of Clinical denials requiring background and understanding from a provider operational and payer logistical perspective. Auditor must work with a diverse group of other health care professionals to conduct review and appeal of Clinical denials related to all Payor plans. Represents Avanti Hospitals from a system perspective when working with payers to challenge and overturn denials of Clinical nature. Manages overturn rate data and evaluates trends for improvement opportunities. Works as part of the team to develop meaningful information for Hospitals and other stakeholders to improve operational performance and cash collections. Nurse auditor must have knowledge of government/State policies. The auditor should have strong project management and analytical skills and be able to handle projects simultaneously. Auditor should be able to work well individually or as part of a team. Assists with chart and Defense audits with outside payors. Assist with CDM charge and coding reviews.

Reports To:  Manager - Contracts and Denials Management

Essential Job Duties: 

  • Evaluates all Clinical denials for possible overturn opportunity. Prepares Appeals as required. Works closely with payers both on the phone and through electronic means to resolve denials and receive payment on accounts.
  • Works as part of a team to develop and administer all Clinical denial workflows and processes.
  • Works closely with Case Managers and Collection Manager to review cases and provide guidance in understanding the interplay between clinical and technical denials
  • Tracks and manages denied accounts, including triaging denials with the Case Managers and Collections Manager to quickly and expeditiously evaluate collectability.
  • Based on initial review of accounts, manages various “buckets” of issues across Hospitals to resolution.
  • Identifies and escalates consistent issues and trends with payers to support
  • Leadership when meeting with payers to resolve issues.
  • Provides fact-based information to Leadership on a regular basis on
  • Clinical denial performance with recommendations on process improvements to avoid denials in the future.
  • Complies with Federal, State, and Local Laws that govern business practices.
  • Understands and abides by all departmental policies and procedures as well as the Code of Ethics, HIPAA requirements and patient rights.
  • Performs other job related tasks, and special projects as assigned.
  • Assists with chart and Defense audits with outside payors.
  • Assist with CDM charge and coding reviews.
  • Assists with disputes and reviews and discusses with patients
  • Documents findings in financial systems and in report excel format
  • Works correspondence pertaining to Clinical denials
  • Communicates with Billing and Collections departments, and other Revenue Cycle departments.
  • Creatively applies job knowledge and experience to solve difficult problems and regularly provides suggestions for quality improvement.
  • Works with Leadership to recommend ways to maximize the use of the department to support strategic and operational needs of the Hospital.
  • Works with Leadership to identify training and system gaps and develop strategies to address these gaps.
  • Complies with Federal, State, and Local Laws that govern business practices.
  • Performs all other duties as assigned

Behavioral Standards: 

  • Exhibits customer and service oriented behaviors in every day work interactions.
  • Demonstrates a courteous and respectful attitude to internal workforce and external customers.
  • Communicates accurately and appropriately.
  • Works well and efficiently under minimal supervision.
  • Handles difficult situations in a discreet and professional manner.
  • Demonstrates a willingness to act as a representative of the hospital.
  • Maintains a good attendance record.
  • Adheres to timekeeping procedures at all times.
  • Is adaptable to changes in assignments and priorities.


  • Provides accurate and timely written and verbal communication of information in a manner that is understood by all.   
  • Able to listen, understand, problem-solve, and carry-out duties to ensure the optimal outcome.
  • Able to use IT systems in an accurate and proficient manner.


  • Contributes toward effective, positive working relationships with internal and external colleagues.
  • Demonstrates cooperation, flexibility, reliability, and dependability in all daily work activities and a willingness to collaborate with others for the good of the customer and the organization.

Job Requirements


  • Must be registered or licensed vocational nurse in California
  • Prefer at least 2 to 3 years of current experience in an acute care hospital setting
  • Excel knowledge a must


  • Must be registered (RN) or licensed vocational nurse (LVN) in California

ADA/Physical Demands:

  • To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed are representative of the knowledge, skill, and/or ability required.  Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant in order to be considered.
  • Required to stand; walk; sit; use hands to fingers, handle, or feel; reach with hands and arms; stoop, kneel, crouch, or crawl; talk and hear; and may taste and smell.  The employee is regularly required to lift, push and/or pull weights in excess of 10 pounds, with assistance. Visual abilities, auditory abilities, must be intact to perform duties.