Electronic Medical Records Auditor​/RN

The Electronic Medical Records (EMR) RN will perform quality monitoring of patient information in transcribed reports. Reviews electronic patient records for coding accuracy, documentation completeness, and compliance with regulations (HIPAA, CMS), identifying errors, providing feedback/training to clinical staff, and generating reports to prevent financial loss and ensure proper billing, often specializing in areas like ICD-10/CPT coding and CDI (Clinical Documentation Improvement).

The ideal candidate combines strong clinical nursing experience with a passion for technology, data accuracy, and process improvements.

Full Time or Part Time:
Full Time

Standard Hours per Week:
Monday – Friday, 40 hours/week

Work Schedule:

Shift starts 8:00 AM – 5:00 PM

Schedule Type:
In Office

• Coordinate the ordering of medical record and ensure accurate documentation and tracking of records and related payments.
• Verify eligibility based on plan benefits and language, and stop-loss policy provisions; accurately enter claim details into the system of record.
• Manage and maintain electronic claim files to support audit processes and ensure compliance with applicable regulations.
• Review, analyze, and adjudicate high-dollar and complex medical stop-loss claims;
  Identify cost-containment opportunities and implement strategies with carriers and TPAs.
• Document audit findings and maintain accurate records in the system.
• Offer guidance to clients on claims procedures and coverage issues.
• Stay current on regulatory requirements impacting clinical documentation and data use (risk adjustment, HIPAA).
• Receive, log, and validate incoming medical records and related documentation; request missing information as needed.
• Develop and maintain EMR templates, documentation standards, and clinical data elements aligned with analytical needs.
• Communicate effectively and respond timely to TPAs, brokers, policyholders, and internal teams; provide clear updates on claim status and documentation requirements.
• Prepare detailed reports on audit findings, trends, and recommendations for management and Stakeholders
• Accurately process and record lump sum payments in the system.

• Requires a Bachelor’s of Science in Nursing or advanced degree preferred
• Specialty in Oncology, Cardiology preferred
• Minimum 5-10 years in medical stop-loss claims processing or related health insurance claims roles.
• Proficiency in medical coding (ICD-10, CPT, HCPCS); advanced Excel skills; expertise with claims processing systems.
• Strong understanding of stop-loss insurance, plan documents, and claims handling practices
• Analytical and problem-solving skills for identifying systemic issues.
• Auditing experience preferred
• Exceptional analytical ability, attention to detail, and strong written and verbal communication skills.