Clinical Audit & Integrity Specialist
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Job Location:
Indianapolis, IN - USA
Monthly Salary:
Not Disclosed
Posted on:
22 hours ago
Vacancies:
1 Vacancy
Job Summary
At Commence were the start of a new age of data-centric transformation elevating health outcomes and powering better more efficient process to program and patient health. We combine quality data-driven solutions that fuel answers technology that advances performance and clinical expertise that builds trust to create a more efficient path to quality care.
With human-centered healthcare-relevant and value-based solutions we create new possibilities with data. We provide proof beyond the concept and performance beyond the scope with a focus on efficiencies that transform the lives of those we serve. With a culture driven by purpose straightforward communication and clinical domain expertise Commence cuts straight to better care.
Clinical Audit & Integrity Specialists provide essential medical expertise to support audit and investigation activities review medical records and make clinical determinations regarding medical necessity appropriateness of care and compliance with clinical standards. This position requires an Indiana nursing license (RN or higher) and the ability to apply clinical knowledge to fraud detection and recovery activities. Clinical Staff work closely with auditors and investigators to ensure medically sound findings.
- Review medical records to assess medical necessity and appropriateness of services
- Provide clinical expertise on audit findings and investigation cases
- Evaluate whether services provided meet accepted standards of care
- Assess documentation quality and completeness to support billing
- Identify medically unnecessary excessive or inappropriate services
- Collaborate with auditors on clinical aspects of overpayment calculations
- Prepare clinical summaries and findings for inclusion in audit reports
- Provide education to audit staff on clinical issues and terminology
- Consult with specialized practitioners (dentists pharmacists) as needed
- Participate in case conferences and provide clinical perspective
- Stay current on clinical practice guidelines and Medicaid coverage policies
- May provide testimony in administrative hearings regarding clinical findings
Required Qualifications
- Current and active Indiana Registered Nurse (RN) license or higher
- Bachelor of Science in Nursing (BSN) preferred
- Advanced practice certifications (NP CNS) valued
- Coding certifications (CPC CCS) beneficial
- Minimum 3 years of clinical nursing experience in acute care or specialty practice
- Experience with utilization review case management or quality assurance preferred
- Medical record review experience highly valued
- Familiarity with Medicaid program and coverage policies beneficial
Knowledge and Skills
- Strong clinical knowledge across multiple specialties and care settings
- Understanding of medical necessity criteria and documentation requirements
- Familiarity with medical coding and clinical documentation standards
- Ability to identify clinically inappropriate or excessive services
- Excellent medical record review and analysis skills
- Strong written and verbal communication abilities
- Critical thinking and clinical judgment
- Ability to collaborate with non-clinical team members
Other Requirements
- Available for meetings and consultations as needed
- Successfully pass background check
- Subject to State approval
is committed to providing equal employment opportunities to all applicants including individuals with disabilities. If you require a reasonable accommodation to participate in the application process due to a disability please contact Human Resources at or Please note that unless you are requesting accommodation all applications must be submitted through our online application system.
Required Experience:
IC
Key Skills
- IDS
- System Design
- Haskell
- PCB
- Root cause Analysis
- Technical Writing
- System Security
- Federal Aviation Regulations
- Warehouse Distribution Experience
- Encryption
- Product Development
- Contracts
About Company
Commence delivers data transformation and clinical expertise that improve care access, reduce burn, and modernize healthcare systems.
