Aridell Associates, LLC

​Serving tHE Healthcare,

Financial, Insurance, and Public SectorS

Current Job Opportunities

Job Title: Clinical Nurse Audit Lead (Contract Position)
Post Date: 3/7/2025 – 3/28/2025

About Us
Aridell Associates, LLC, a professional consulting firm, advises clients on healthcare program operations and helps clients develop solutions to maximize meaningful outcomes, improve their operations, and protect their valuable assets, as well as bestow customer confidence in their operations.  Our mission is to advance clients’ operational performance and provide sustainable long-term, successful business strategies.


Position Summary
If you are interested in providing consulting and advisory services or supporting contracts, then this operational support position is for you.  The Clinical Nurse Audit Lead is well-versed in utilization management and possess the skills to assess healthcare services to ensure each one is medically necessary, appropriate efficient, while also understanding government insurance program guidelines and cost-containment strategies. The Clinical Nurse Audit Lead serves as an integral member of a multi-disciplinary team in supporting audits focused on health plans for a client. In this position, you will lead teams; assign work activities; oversee work assignments; conduct research; collaborate on developing audit and analytical approaches, methodologies, and strategies; perform fieldwork, and report results. The Clinical Nurse Audit Lead will receive all direction and instructions from a program manager or their designee for the work activities under a contract.  


Responsibilities

  • Provide nursing subject matter expertise (e.g., clinical operations, coding, and documentation) on healthcare policies, programs, regulations, laws, products, services, and billing and payment methodologies in support of audits. 
  • Assess compliance with government laws and regulations.
  • Gather and organize information about a problem to be solved or the procedure or process to be improved.
  • Analyze financial, operational, and performance data, information, and other forms of evidence.
  • Participate in on-site and off-site audit activities.
  • Interact and confer with team members on a variety of topics, such as ideas, projects, approaches, methodologies, and strategies, using all forms of available communications.
  • Identify and aid in the development of best practices for conducting audits.
  • Review and analyze encounter data, fee-for-service claims, enrollment data, prescription drug event records, and other data sources in providing advice, input, and recommendations.
  • Interpret Medicare policies, laws, rules, regulations, manuals, and healthcare industry guidelines in conducting audits.
  • ​Educate and explain coding practices and the coding process to clients and team members as needed.
  • Serve as a technical resource in health plan operations and data.
  • Mentor, educate, and train other audit and analytical personnel, as well as partners and stakeholders. 


Qualifications

  • The position requires a Bachelor of Science in Nursing or related field. The nature of the work requires a minimum of 10 years of experience supporting government, compliance, and program integrity operations. Experience working for a health plan, regulatory government agency, special investigation unit, and program integrity contractor is preferred.
  • Must possess substantial familiarity with federal healthcare programs, such as Medicare Advantage Organizations, Medicare Prescription Drug Plans, and the Program of All-Inclusive Care for the Elderly (PACE), and the governing laws, rules, regulations, and policies. Preference is given to candidates with outstanding organizational, time management, and interpersonal skills; superior technical writing and research ability; and a demonstrated commitment to professionalism and ethics.
  • The role requires one with a familiarity with managed care audits.

 
Knowledge and Skills

  • Must have a strong foundation in nursing care and an understanding of the medical aspects of patient care and treatment plans.
  • Strong experience in reviewing medical records to assess claims and encounter data.
  • Knowledge of prior authorizations, coverage determinations, appeals, and grievances and the associated operations and regulations.
  • Experience with assessing medical necessity based on evidenced-based clinical standards.
  • Knowledge of healthcare systems, including insurance reimbursement guidelines and regulations.
  • Ability to analyze data and reports to identify trends and areas for improvement in healthcare settings.
  • Knowledge of CPT, DRG, HCPCS, ICD-9, and ICD-10 codes. 
  • Strong organizational planning and prioritization skills with the ability to collaborate with others and multi-task.
  • Excellent written and verbal communication skills.
  • Ability to present to large or small groups when required.
  • Proficient in using the Microsoft Office Professional Suite, including Word, Excel, PowerPoint, and Outlook.


Travel Requirements
Occasional travel to audit sites is required. Travel is reimbursable.


Job Location
This is a work-from-home/remote position.

Apply Now
Email a cover letter and resume To: jarias@aridell.com​​​