Sr Clinical Auditing Specialist

Company Overview: Health Network One (HN1) partners with health plans and providers to modernize how specialty care is delivered and managed, reducing complexity, driving better performance, and improving lives.

With over 30 years of experience, Health Network One advances care in several unique specialties: Total Eye, Sleep Well, Pure Derm and Thrive Therapy. By curating specialty networks and credentialing providers who meet rigorous access and quality standards, we bring together value-based models and clinical expertise to ensure providers thrive, payers succeed, and members receive the high-quality care they deserve.

Position Summary:

The Senior Clinical Auditing Specialist is responsible for leading and executing comprehensive clinical audits, including utilization management (UM), claims auditing, and appeals and grievances review. This role ensures compliance with regulatory standards, supports continuous quality improvement, and safeguards the integrity of clinical and financial operations. The ideal candidate brings deep expertise in healthcare auditing, a strong understanding of clinical practices, and preferably holds a current RN license or equivalent clinical credential.

Key Responsibilities:

• Conduct detailed audits of clinical documentation, UM activities, medical necessity and healthcare claims coding to validate and ensure accuracy, compliance, and quality of care.
• Review and analyze appeals and grievances, collaborating with clinical and administrative teams to resolve complex cases and ensure fair outcomes.
• Develop and perform inter-rater reliability (IRR) monitoring for UM activities.
• Evaluate medical records, treatment plans, and billing data for adherence to regulatory requirements and payer guidelines.
• Identify trends, discrepancies, and areas for improvement; prepare comprehensive audit reports with actionable recommendations.
• Collaborate with clinical staff, management, and external partners to implement corrective actions and drive process improvements.
• Provide education and training to staff on clinical documentation standards, compliance matters, and audit findings.
• Stay current on changes in healthcare regulations, coding standards (ICD-10, CPT, DRG), and best practices in clinical auditing.
• Support accreditation and quality improvement initiatives, contributing to policy development and readiness assessments.
• Maintain meticulous records and documentation to support audit activities and regulatory reviews.
• Participate in internal and external audits, regulatory inspections, and accreditation surveys as needed.

Qualifications:

• Bachelor’s degree in nursing, healthcare administration, or a related clinical field (Master’s preferred).
• Active RN license or equivalent clinical credential strongly preferred.
• Minimum of 5 years of experience in healthcare auditing, utilization management, claims review, or related clinical quality roles.
• Demonstrated expertise in clinical documentation, medical coding, and regulatory compliance.
• Experience managing appeals and grievances in a healthcare setting.
• Strong analytical, organizational, and communication skills
• Proficiency with electronic health records (EHR/EMR), audit management tools, and Microsoft Office Suite.
• Relevant certifications (e.g., CPHQ, CPMA, CPC, CCS) are highly desirable.

Preferred Skills:

• Advanced knowledge of payer contracts, reimbursement methodologies, and healthcare regulatory frameworks.
• Experience presenting audit findings and recommendations to leadership.
• Ability to work independently and collaboratively in a fast-paced environment.
• Commitment to ongoing professional development and quality improvement