Clinical Nurse Auditor for DRG & Denials Review

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 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