Top 9514 Rn Clinical Coordinator Jobs

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WellSense Health Plan —Remote
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- Nursing
- RN License
- Bachelor's degree
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- Up to 50% travel
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Umpqua Health —Remote
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RN, Admitting&Transfer Center
University of Rochester —Rochester, NY
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MJHS —New York, NY
- $110,000 - $120,000 a year
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Quality Coordinator Quality Management & Performance Excellence
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Clinical Review Nurse - Prior Authorization
Akido —Chino, CA
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RN Utilization Review Coordinator, Full-time
Methodist Hospital for Surgery —Addison, TX
- Full-time
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RN Director of Mental Health Program (External Posting)
The Richland Hospital —Remote
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RN Quality Coordinator
AdventHealth Riverview —Riverview, FL
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13d
Donation Coordinator
Gift of Life Michigan —Ann Arbor, MI
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- Nursing
- Microsoft Outlook
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RN Care Coordinator
Scenic Rivers Health Services —Bigfork, MN
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MDS Coordinator
Advanced Center for Nursing and Rehabilitation —New Haven, CT
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- RN License
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Registered Nurse (RN) Manager
DAVITA —Manchester, NH
- Weekends as needed
- Microsoft Word
- CPR Certification
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RN MDS Coordinator/Case Manager
Lake Forest Health & Rehabilitation —Smithfield, RI
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- Full-time
- Anatomy knowledge
- RN License
- Mid-level
- Disability insurance
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Director of Nursing (DON) - RN
Gateway Vista —Lincoln, NE
- $95,000 - $115,000 a year
- 8 hour shift
- Background check
- Nursing
- Skilled nursing facility
- Health savings account
- Loan repayment program
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CNA Instructor - RN
Wisconsin Illinois Senior Housing Inc. WISH Home Office —Merrill, WI
- $40 an hour
- Full-time
- Classroom
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- RN License
- Health insurance
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Nursing Clinical Coordinator
Eastern International College —Jersey City, NJ
- $90,000 - $95,000 a year
- Full-time
- Background check
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- RN License
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RN Case Manager
Onewell Healthcare - South Carolina —Bluffton, SC
- $37 - $41 an hour
- Full-time
- Nursing
- RN License
- Mid-level
- Paid training
- Health insurance
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Staff Development Coordinator/Infection Control RN
Medilodge of GTC —Traverse City, MI
- Nursing
- RN License
- Computer literacy
- Health savings account
- Loan repayment program
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14d

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Clinical Auditor I-Nurse

WellSense Health Plan -
Remote

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Job Details

Full-time
$64,000 - $93,000 a year

Benefits

Health insurance
Dental insurance
Flexible spending account
Paid time off
Vision insurance
403(b)
Opportunities for advancement

Qualifications

Nursing
RN License
Nursing

Full Job Description

It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

Job Summary

The Clinical Auditor I performs detailed medical record audit review and analysis of the health plan’s outpatient, professional and ancillary claims to ensure that all reimbursement to the provider is paid accurately and ensuring adherence to regulations, internal policies and best practice of patient care.

Our Investment in You:

Full-time remote work

Competitive salaries

Excellent benefits

Key Functions/Responsibilities:

Analyze patient records, treatment plans, and medical billing documents to ensure accuracy, completeness, and strict compliance with healthcare standards and regulations.

Verify that procedures and diagnoses are accurately coded using appropriate CPT, HCPCS, and ICD-10 codes. Ensure that the coding reflects the clinical documentation accurately and complies with current guidelines.

Check for consistent documentation across patient records, confirming that all entries adhere to regulatory mandates, internal policies, contract stipulations, and benefit coverages.

Identify any documentation or billing discrepancies during the review process. This includes spotting errors, omissions, or inconsistencies that may affect reimbursement or patient care quality, and flagging these issues as needed.

Based on audit findings, regularly update and refine clinical audit guidelines and protocols.

Use statistical and analytical methods to examine clinical data.

Methodically review data to identify discrepancies and irregularities that could indicate non-compliance with internal policies, contractual obligations, or regulatory mandates.

Analyze data trends to determine potential areas of risk that might adversely affect patient care or disrupt the organization’s operations.

Continuously monitor and document recurring patterns or anomalies in clinical data.

Based on the insights gathered, provide well-founded recommendations for new audit projects.

Conduct both scheduled and ad hoc audits in strict accordance with established guidelines and internal processes. This involves planning and executing audit activities to ensure every clinical record is reviewed consistently while aligning with quality assurance benchmarks.

Develop comprehensive audit reports that clearly outline all findings. Reports must detail discrepancies, note any process inefficiencies, and provide precise, actionable recommendations for improvement.

Play a supportive role in the amendment and appeals process. This includes coordinating with providers to resolve discrepancies and ensuring the audit conclusions are fully and fairly reviewed.

Finalize all audits by ensuring that all findings are documented, follow-up actions are clearly communicated, and the entire process meets the established timelines and productivity standards for the role.

Collaborate closely with clinical staff, audit coordinator, and other members of the audit team on audit findings and questions.

Maintain active communication with providers by preparing precise documentation, responding promptly to emails and phone calls, and offering detailed explanations of audit results.

Ensure that any audit denial rationale is clearly, concisely, and accurately communicated.

Continuously monitor evolving federal and state healthcare regulations along with industry standards by engaging in regular education and policy reviews. Ensure that all clinical documentation and audit processes are consistently aligned with current regulatory requirements and best practices.

Evaluate clinical and reimbursement activities to determine payment compliance under WellSense clinical and reimbursement policies.

Proactively identify potential fraud and abuse by scrutinizing clinical data, documenting billing errors, and highlighting opportunities to manage benefit costs and secure savings.

When discrepancies or irregularities signal deeper issues, refer cases to the Special Investigations Unit (SIU) or the Third-Party Liability team.

Detect potential quality of care or utilization issues during audits and promptly report these findings to management.

Assist in educating clinical personnel on documentation requirements and audit practices to enhance compliance and overall patient care quality.

Qualifications:

Bachelor's degree in nursing or an equivalent combination of education, training, and experience is required.

Two years CM, UM, claims auditing or other clinical health insurance role

Two years minimum RN experience in acute care setting

Behavioral Health and/or Inpatient DRG experience required

Certification or Conditions of Employment:

Valid Registered Nurse License required

Coding Certification Preferred - CPC or CCS certification

Basic familiarity with CPT, ICD-10 and HCPCS coding is preferred

Claims processing experience is preferred

Compensation Range

$64,000 - $93,000

This range offers an estimate based on the minimum job qualifications. However, our approach to determining base pay is comprehensive, and a broad range of factors is considered when making an offer. This includes education, experience, skills, and certifications/licensure as they directly relate to position requirements; as well as business/organizational needs, internal equity, and market-competitiveness. In addition, WellSense offers generous total compensation that includes, but is not limited to, benefits (medical, dental, vision, pharmacy), merit increases, Flexible Spending Accounts, 403(b) savings matches, paid time off, career advancement opportunities, and resources to support employee and family wellbeing.

Note: This range is based on Boston-area data, and is subject to modification based on geographic location.

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

Apply Now

Refine Your Search

Rn Clinical Coordinator jobs

Clinical Auditor I-Nurse

Clinical Nurse Coordinator - Transplant

Utilization Review Nurse

RN, Admitting&Transfer Center

A&G RN Coordinator

Quality Coordinator Quality Management & Performance Excellence

Clinical Review Nurse - Prior Authorization

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RN Quality Coordinator

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RN Care Coordinator

MDS Coordinator

Registered Nurse (RN) Manager

RN MDS Coordinator/Case Manager

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CNA Instructor - RN

Nursing Clinical Coordinator

RN Case Manager

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