Commence · 14 hours ago
Clinical Audit & Integrity Specialist
Indianapolis, IN
Full-time
Onsite
Mid Level
3+ years expCommence is at the forefront of data-centric transformation in healthcare, aiming to elevate health outcomes through innovative solutions. The Clinical Audit & Integrity Specialist will provide essential medical expertise to support audit and investigation activities, ensuring compliance with clinical standards and appropriateness of care.
AnalyticsArtificial Intelligence (AI)Clinical TrialsCloud ComputingHealth CareSoftware
Responsibilities
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
Qualification
Required
Current and active Indiana Registered Nurse (RN) license or higher
Minimum 3 years of clinical nursing experience in acute care or specialty practice
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
Available for meetings and consultations as needed
Successfully pass background check
Subject to State approval
Preferred
Bachelor of Science in Nursing (BSN) preferred
Advanced practice certifications (NP, CNS) valued
Coding certifications (CPC, CCS) beneficial
Experience with utilization review, case management, or quality assurance preferred
Medical record review experience highly valued
Familiarity with Medicaid program and coverage policies beneficial
Company
Commence
Commence delivers AI-driven healthcare data platform and clinical expertise that supports analytics, decisions, and workflow improvement.
501-1000 employees
Funding
Current Stage
Late StageCompany data provided by crunchbase