Nurse Defense Auditor job at MD Anderson Cancer Center in Houston, TX

Title: Nurse Defense Auditor Location: Houston United States Remote Job Description: As a Nurse Defense Auditor in our Hospital Billing & Collections department, your expertise ensures accurate reimbursement and supports patient access to life-saving care. This role combines clinical knowledge, insurance expertise, and critical thinking to resolve complex denials and audits-making a direct impact on patient outcomes and organizational success. MD Anderson offers our employees: Paid Medical Benefits for employees and eligible dependents Generous Paid Time Off (PTO) for work-life balance Retirement Plans with employer contributions Career Development Opportunities and tuition assistance Additional perks such as wellness programs, employee discounts, and more The primary purpose of the Nurse Defense Audit Coordinator position within the Hospital Billing & Collections department is to utilize clinical expertise, insurance knowledge, business acumen, and strong communication skills to analyze patient accounts and invoices for retrospective approval of denied services and potential continued access needs. This role also includes conducting retrospective reviews and audits of patient accounts to complete Defense Audits. Ideal Candidate: A Registered Nurse (RN) with experience in appeals and nurse defense auditing. Key Functions Analyze invoices and accounts in the patient accounting system to prepare for appeals of third-party payer denials. Utilize Explanation of Benefits (EOB) and Remittance Advices to verify denials and identify possible avenues of appeal. Contact third-party payers, insurance medical directors, case management, and utilization review to request reconsideration and/or appeal of claims requiring clinical intervention, ensuring comprehensive data is provided to justify appeals. Evaluate and audit medical records to support Defense Audits, confirming services were provided and billed accurately. Review for overcharges and missing charges, and discuss findings with outside auditors. Collaborate with Case Management and providers to ensure all medical necessity documentation is captured. Coordinate appeal or audit processes and maintain appropriate follow-up on appealed/audited claims. Update and document patient accounting system accurately and efficiently, including insurance, demographics, notations, and service codes. Communicate with leadership regarding issues impacting future care needs and contract performance. Demonstrate thorough knowledge of third-party payer claim requirements, UB04, HCFA1500, EOBs, and appeal timelines. Maintain understanding of insurance guidelines for medical necessity review, including M&R and InterQual, and working knowledge of ICD-10 and CPT codes. Stay current on oncology clinical processes and outcomes, including clinical trials and related resources. Perform related business office responsibilities with minimal supervision, demonstrating innovation, good judgment, and adherence to ethical and legal billing procedures. Follow hospital and department policies and maintain confidentiality in all matters. Actively contribute to a team approach, offering positive suggestions and ideas for improved revenue recovery and team success. EDUCATION Required: Graduation from an accredited school of nursing. Preferred: Bachelor's Degree Nursing. WORK EXPERIENCE Required: 5 years Experience in clinical nursing and 1 year Experience in utilization review. May substitute preferred degree for two years of the five clinical nursing experience. Preferred: Nurse Defense Audit experience, experience with insurance appeals, prior case management or business office experience. Work Schedule: This position is remote. Prefer Houston/local area. LICENSES AND CERTIFICATIONS Required: RN - Registered Nurse - State Licensure State of Texas Professional Nursing License (RN). Upon Hire and Required: BLS - Basic Life Support Upon Hire or Required: CPR - Cardiac Pulmonary Resuscitation Upon Hire Preferred: CM - Case Management Upon Hire Preferred: ACLS - Advanced Cardiac Life Support Certification as required by patient care area. Upon Hire Preferred: PALS - Pediatric Advanced Life Support Certification as required by patient care area. Upon Hire The University of Texas MD Anderson Cancer Center offers excellent benefits, including medical, dental, paid time off, retirement, tuition benefits, educational opportunities, and individual and team recognition. This position may be responsible for maintaining the security and integrity of critical infrastructure, as defined in Section 113.001(2) of the Texas Business and Commerce Code and therefore may require routine reviews and screening. The ability to satisfy and maintain all requirements necessary to ensure the continued security and integrity of such infrastructure is a condition of hire and continued employment. It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state, or local laws unless such distinction is required by law. Additional Information Requisition ID: 177616 Employment Status: Full-Time Employee Status: Regular Work Week: Days Minimum Salary: US Dollar (USD) 89,000 Midpoint Salary: US Dollar (USD) 111,000 Maximum Salary : US Dollar (USD) 133,000 FLSA: exempt and not eligible for overtime pay Fund Type: Hard Work Location: Remote (within Texas only) Pivotal Position: Yes Referral Bonus Available?: No Relocation Assistance Available?: No Apply tot his job