Clinical Appeal Revenue Integrity Nurse Auditor

CentraState Healthcare System, headquartered in Freehold, New Jersey, is a leading nonprofit healthcare provider dedicated to serving the community. Its comprehensive network includes CentraState Medical Center, a community-focused hospital, along with an ambulatory campus, two senior living facilities, three free-standing community health pavilions, and a charitable foundation. As the third-largest employer in Monmouth County, CentraState has earned repeated recognition as a Great Place to Work-Certified company, reinforcing its reputation as an exceptional workplace.

CentraState currently has an employment opportunity available for a Clinical Appeal Revenue Integrity Nurse Auditor.This role is responsible for auditing documentation, ensuring documentation meets medical necessity requirements, constructs appeal letters, following all federal, state and payer requirements.

They serve as a liaison between clinical, coding, billing, compliance, and finance teams to promote best practices in revenue cycle operations.They will work with hospital departments including Case Management/Utilization Review, Health Information Management, Patient Financial Services, Ancillary Departments, Physicians and Nursing. They will analyze audit trends, communicate findings and collaborate with Revenue Cycle on goals and opportunities for improvement.

Review clinical denials and identify root causes

• Write clinical appeal letters and medical necessity reviews

• Write and submit thorough, concise, fact-based appeals to insurance companies when a service has been denied or unpaid

• Partner with Revenue Cycle Team in methods of denials prevention

• Conduct education and presentations re: denials for hospital wide denials prevention

• Track and trend denial patterns and work collaboratively on actions plans to reduce denials

• Conduct prospective and retrospective audits related to coding, billing and clinical documentation

• Identify trends related to underpayment, overpayment or denials

• Ensure compliance with Medicare, Medicaid and commercial payor guidelines and all state and federal regulations

• Assist in responding to payor audits, internal audits and compliance investigations

• Review clinical documentation to ensure accuracy, completeness, and compliance with regulatory and payer requirements

• Identify documentation gaps affecting reimbursement and quality reporting

• Collaborate with Physicians, Nurses, CDI and Coding teams on denials prevention

• Support correct assignment of ICD-10, CPT and charge codes

• Provide education on best practices and regulatory requirements of documentation

• Analyze data and identify revenue integrity risks, trends, and improvement opportunities

• Prepare reports and dashboards related to audit findings, denials and compliance metrics

• Support leadership with recommendations for process improvement initiatives

• Join and participate in national organizations to educate and improve appeal decisions and processes

• Performs other responsibilities within the revenue integrity departments as assigned

• Bachelor's degree in Nursing required.
• Minimum of 3-5 years of RN clinical experience required, acute care preferred.
• Current NJ RN License required.
• Strong understanding of medical necessity criteria, clinical documentation standards, and revenue cycle processes.
• Strong Clinical judgement and analytical skills
• High attention to detail and accuracy
• Excellent written and verbal communication
• Ability to interpret regulatory and payer guidance
• Strong collaboration and relationship-building skills to effectively relate with all members of the healthcare team
• Ability to manage multiple priorities independently
• Proficiency with EPIC, Microsoft Office (Excel, Word, PowerPoint)

CentraState Healthcare System, in partnership with Atlantic Health System, is a fully accredited, not-for-profit, community-based health system dedicated to providing comprehensive health services in central New Jersey. Beyond offering a wide range of advanced diagnostic and treatment options, CentraState is committed to being a valuable health partner, focusing on disease prevention, promoting healthy behaviors, and helping individuals of all ages live well.

Located in Freehold, CentraState includes a 284-bed acute-care hospital, a dynamic health and wellness campus, two award-winning senior living communities, a charitable foundation, and convenient satellite health pavilions. These pavilions offer primary care, specialty physician practices, and access to outpatient services such as lab work and physical therapy.

CentraState is proud to be among the less than two percent of hospitals nationwide to earn Magnet designation for nursing excellence five times. Additionally, it has been recognized as a Great Place to Work-Certified Company by Great Place to Work for four consecutive years.

Joining CentraState means becoming part of a pioneering healthcare facility committed to high-quality, patient-focused care. We invite you to make a difference in our community and advance your career with us. We support our employees with work/life balance initiatives, tuition assistance, career advancement opportunities, and more.

Discover why our employees love their jobs and being part of the CentraState family!

CentraState Health System offers a competitive and comprehensive Total Rewards package that supports the health, financial security, and well-being of all team members.

What We Offer:

• Medical, Dental, Vision, Prescription Coverage (30 hours per week or above for full-time and part-time team members)
• Life & AD&D Insurance
• Long-Term Disability (with options to supplement)
• 403(b) Retirement Plan with employer match
• 401(a) Retirement Plan with employer contribution
• PTO
• Tuition Reimbursement
• Well-Being Rewards
• Employee Assistance Program (EAP)
• Fertility Coverage, Healthy Pregnancy Program
• Flexible Spending & Commuter Accounts
• Pet, Home & Auto, Identity Theft and Legal Insurance
• Growth Opportunity and Workforce Development Initiatives
• Continuing Education / Onsite Training
• A warm, welcoming company culture based upon mutual respect and a collaborative goal of providing excellent patient care
• Concierge Services with Work & Family Benefits
• Magnet recognized healthcare facility

Compensation Range: $93,600 - $159,120

The compensation above reflects the established range from CentraState Healthcare System (CSHS) for this position at the time the job was posted. CSHS considers many factors to determine compensation, including education, experience, skills, licenses, certification, and training. As such, team member compensation may fall outside this range.

Additionally, the compensation range reflects base salary and does not include extra shift rates or incentives tied to quality, productivity, etc., as applicable.

The benefits outlined also reflect CSHS' policy at the time of posting. Benefits as are made available to other similarly situated team members of CSHS, although participation is at all times in accordance with and subject to the eligibility and other provisions of such plans and programs. CSHS may modify its benefits plans or programs at any time.

CSHS is proud to comply with all pay equity and pay transparency laws.