Nurse Defense Auditor

As a Denials Management Coordinator in our Hospital Billing & Collections department, your expertise ensures accurate reimbursement and supports patient access to life-saving care. This role combines clinical knowledge, insurance expertise, and critical thinking to resolve complex denials and audits—making a direct impact on patient outcomes and organizational success.

MD Anderson offers our employees:

• Paid Medical Benefits for employees and eligible dependents
• Generous Paid Time Off (PTO) for work-life balance
• Retirement Plans with employer contributions
• Career Development Opportunities and tuition assistance
• Additional perks such as wellness programs, employee discounts, and more

The primary purpose of the Denials Coordinator–Audit Coordinator position within the Patient Business Services (PBS) department is to utilize clinical expertise, insurance knowledge, business acumen, and strong communication skills to analyze patient accounts and invoices for retrospective approval of denied services and potential continued access needs. This role also includes conducting retrospective reviews and audits of patient accounts to complete Defense Audits.

Ideal Candidate: A Registered Nurse (RN) with experience in appeals and nurse auditing.

Key Functions

• Analyze invoices and accounts in the patient accounting system to prepare for appeals of third-party payer denials. Utilize Explanation of Benefits (EOB) and Remittance Advices to verify denials and identify possible avenues of appeal.
• Contact third-party payers, insurance medical directors, case management, and utilization review to request reconsideration and/or appeal of claims requiring clinical intervention, ensuring comprehensive data is provided to justify appeals.
• Evaluate and audit medical records to support Defense Audits, confirming services were provided and billed accurately. Review for overcharges and missing charges, and discuss findings with outside auditors.
• Collaborate with Case Management and providers to ensure all medical necessity documentation is captured.
• Coordinate appeal or audit processes and maintain appropriate follow-up on appealed/audited claims.
• Update and document patient accounting system accurately and efficiently, including insurance, demographics, notations, and service codes.
• Communicate with leadership regarding issues impacting future care needs and contract performance.
• Demonstrate thorough knowledge of third-party payer claim requirements, UB04, HCFA1500, EOBs, and appeal timelines.
• Maintain understanding of insurance guidelines for medical necessity review, including M&R and InterQual, and working knowledge of ICD-10 and CPT codes.
• Stay current on oncology clinical processes and outcomes, including clinical trials and related resources.
• Perform related business office responsibilities with minimal supervision, demonstrating innovation, good judgment, and adherence to ethical and legal billing procedures.
• Follow hospital and department policies and maintain confidentiality in all matters.
• Actively contribute to a team approach, offering positive suggestions and ideas for improved revenue recovery and team success.