Clinical Nurse Auditor

Rev Pro; Philippines; On-site; PHP 350,000 - 650,000; Full time

Job summary

KAVI Philippines is seeking a Clinical Nurse Auditor to perform comprehensive clinical audits for high-complexity claims in the Philippines. This role ensures medical necessity, regulatory compliance, and adherence to payer guidelines, applying clinical judgment for admission status, level of care, and coverage determinations.

You will collaborate with internal and external stakeholders to support accurate reimbursement and clinical appeals, with emphasis on accuracy, detail, and timely

Qualifications

• Minimum 2 years of experience in medical necessity reviews and admission/length of stay determinations.
• Experience interpreting LCD/NCD and applying payer policies.
• DRG validation and downgrade reviews experience.
• Line-item clinical reviews experience.
• Strong knowledge of CMS guidelines and regulatory standards.

Responsibilities

• Review, analyze, and resolve high-complexity claims and denials requiring advanced clinical judgment and regulatory expertise.
• Determine appropriate admission type, level of care, length of stay, care setting, and coverage based on documentation and payer rules.
• Apply medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG, LCD/NCD).
• Perform line-item reviews to validate accuracy and reimbursement integrity.
• Review DRG assignments and downgrades; document opinions and recommendations with clinical evidence.
• Identify trends and risks across audit findings and communicate results to leadership and partners.

Skills

Clinical auditing

Payer policies

CMS guidelines

Analytical thinking

Attention to detail

Education

BSN - Bachelor of Science in Nursing

Registered Nursing US License

Tools

EMR/EHR systems

Job description

KAVI Philippines is seeking a Clinical Nurse Auditor to perform comprehensive clinical audits for high-complexity claims. This role ensures medical necessity, regulatory compliance, and adherence to payer guidelines. You will apply your clinical judgment to evaluate services, admission status, level of care, and coverage determinations, while partnering with internal and external stakeholders to support accurate reimbursement and clinical appeals.

Communication

Attention to Detail

Analytical Thinking

Technical Tools & Systems

Autonomy & Organization

Responsibilities

• Review, analyze, and resolve high-complexity claims and denials requiring advanced clinical judgment, payer specific interpretation, and regulatory expertise
• Determine appropriate admission type, level of care, length of stay, care setting, and coverage based onclinical documentation and payer-specific rules
• Apply appropriate medical review guidelines, policies, and regulatory standards (CMS, InterQual, MCG,LCD/NCD, and payer-specific policies)
• Perform line-item reviews to validate accuracy, compliance, andreimbursement integrity
• Review DRG assignments and downgrades and identify opportunities for support, correction, or appeal.Document clear, concise opinions, conclusions, and recommendations supported by clinical evidence
• Identify trends, risks, and educational opportunities across audit findings. Communicate results and insightsto internal leadership and external partners in a professional and actionable manner
  

Must Have

• Registered Nursing US License - Bachelor of Science in Nursing

Minimum 2 years of experience in:

Medical necessity reviews

Admission/Length of Stay determinations

LCD/NCD interpretation and application

DRG validation and downgrade reviews

• Line-item clinical reviews

3–5 years acute care hospital experience, preferably in

• Surgery
• Orthopedics
• Strong knowledge of payer policies, CMS guidelines, and nationally recognized medical review standards.
• Excellent written and verbal communication skills.
• Strong analytical skills, attention to detail, and critical thinking.

Nice to Have

• Any professional coding credentials (CPC, CCS,CIC RHIA, RHIT).

Experience with EMR/EHR systems and electronic medical records navigation.

• Ability to communicate audit outcomes to both clinical and non-clinical audiences.
• Familiarity with billing and claims forms (UB, CMS, HCFA).
• Knowledge of trauma/medical/surgical procedures and clinical treatment patterns.

What's great in the job?

• Work with a highly skilled healthcare team in a collaborative and supportive environment
• Directly impact reimbursement accuracy and clinical quality for high-complexity claims
• Opportunity to develop expertise in medical audits, DRG validation, and clinical appeals
• Professional growth: expand your knowledge of payer policies, medical review standards, and hospital operations
• Real responsibilities and meaningful challenges in a fast-evolving healthcare BPO environment