Nurse Defense Auditor

UT MD Anderson; Houston (TX); Hybrid; USD 89,000 - 133,000; Full time

Benefits offered by this job

Employer-paid medical coverage

PTO and holidays

Tuition assistance

Pension plan

Job summary

The University of Texas MD Anderson Cancer Center is seeking a Denials Management Coordinator to support the revenue cycle by reviewing and resolving insurance denials. You will work with clinical, financial, coding, and payer teams to optimize reimbursement and ensure compliance.

The role requires a Registered Nurse with a BSN preferred, with experience in utilization review, appeals, nurse auditing, or related business office operations.

Qualifications

• Must be a Registered Nurse with licensure in Texas.
• BSN preferred for nursing leadership and education responsibilities.
• Experience in front-end or back-end appeals, nurse auditing, utilization review, or related business office operations.
• Familiarity with insurance appeals, medical necessity reviews, and case management preferred.

Responsibilities

• Analyze invoices and patient accounts to prepare appeals for third-party payer denials.
• Utilize EOBs and Remittance Advises to verify denials and identify appeal opportunities.
• Review denied services for retrospective approval, continued access needs, and defense audits.
• Identify denial trends affecting reimbursement and revenue cycle performance.
• Coordinate appeal and audit activities and maintain timely follow-up on appealed or audited claims.
• Collaborate with Case Management, providers, coding, billing, and payer relations teams.
• Document appeal activities, audit outcomes, and account actions; maintain data integrity in the patient accounting system.

Skills

Clinical nursing

Utilization review

Nurse appeals

Nurse auditing

Business office experience

Education

RN license

BSN preferred

Job description

The University of Texas MD Anderson Cancer Center is a leading institution focused on cancer care, research, education, and prevention. The Denials Management Coordinator plays a vital role in supporting the organization's revenue cycle operations by coordinating the review, analysis, and resolution of insurance claim denials to help ensure accurate and timely reimbursement. The Denials Management Coordinator works closely with clinical, financial, coding, billing, and payer teams to support compliant revenue practices and revenue recovery efforts.

Within the Hospital Billing & Collections department, the Denials Management Coordinator analyzes complex patient accounts, denied claims, audits, and appeals while serving as a liaison between internal stakeholders and third-party payers. UT MD Anderson relies on this role to identify denial trends, facilitate retrospective approvals, support defense audits, and improve reimbursement outcomes through effective communication and clinical expertise.

The ideal candidate is a Registered Nurse with a Bachelor's Degree in Nursing preferred, experience with front-end and back-end insurance appeals, nurse auditing, utilization review, case management, or business office operations. Preferred certifications include Case Management, Advanced Cardiac Life Support, and Pediatric Advanced Life Support. The candidate should possess strong knowledge of insurance appeals, medical necessity reviews, nurse defense audit, and case management.

Minimum $89,000 annually - Midpoint $111,000 annually - Maximum $133,000 annually (based on a 40-hour work week)

The typical work schedule is Monday - Friday 8am - 5pm (must be able to come onsite as needed).

Work Location: Remote (must be able to come onsite as needed)

Why Us?

• Employer-paid medical coverage starting day one for employees working 30+ hours/week, plus optional group dental, vision, life, AD&D, and disability insurance.
• Accruals for PTO and Extended Illness Bank, plus paid holidays, wellness, childcare, and other leave options.
• Tuition Assistance Program after six months of service and access to extensive wellness, fitness, and employee resource groups.
• Defined-benefit pension through the Teachers Retirement System, voluntary retirement plans, and employer-paid life and reduced salary protection programs.

Responsibilities

• Analyze invoices and patient accounts in the patient accounting system to prepare appeals for third-party payer denials
• Utilize Explanation of Benefits (EOB) and Remittance Advices to verify denials and identify appeal opportunities
• Review denied services for retrospective approval, continued access needs, retrospective review, and defense audits
• Identify and evaluate denial trends that impact reimbursement and revenue cycle performance

Payer Communication & Resolution

• Contact third-party payers, insurance medical directors, case management, and utilization review teams to request reconsideration and appeals
• Provide comprehensive clinical and financial documentation to support appeal requests
• Coordinate appeal and audit activities and maintain timely follow-up on appealed or audited claims
• Communicate issues affecting future care needs and contract performance to leadership

Clinical & Revenue Cycle Collaboration

• Collaborate with Case Management and providers to ensure all medical necessity documentation is captured
• Serve as a liaison between clinical departments, coding, billing, payer relations, and financial teams
• Promote compliant revenue practices and support accurate reimbursement processes
• Support resolution strategies for complex denials requiring clinical intervention Documentation & System Management
• Update and maintain patient accounting system information, including insurance, demographics, notations, and service codes
• Accurately document appeal activities, audit outcomes, and account actions
• Maintain confidentiality and follow hospital and departmental policies and procedures
• Perform business office responsibilities with minimal supervision while exercising sound judgment

Compliance & Professional Knowledge

• Demonstrate knowledge of third-party payer claim requirements, UB04, HCFA1500, EOBs, and appeal timelines
• Maintain understanding of insurance guidelines related to medical necessity review, including M&R and InterQual
• Apply working knowledge of ICD-10 and CPT codes
• Stay current on oncology clinical processes, outcomes, clinical trials, and related resources
• Contribute ideas and recommendations that improve revenue recovery and team effectiveness

Education

• Required: Graduation from an accredited school of nursing.
• Preferred: Bachelor's Degree Nursing.

Work Experience

• Required: 5 years Experience in clinical nursing. and
• Required: 1 year Experience in utilization review.
• Preferred: Experience with front -end or back-end appeals, insurance appeals, prior case management, nurse auditing, or business office experience.
• May substitute preferred degree for two years of the five clinical nursing experience.

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. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html

Additional Information

• Requisition ID: 183701
• 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: No
• Referral Bonus Available?: No
• Relocation Assistance Available?: No