Nurse Defense Auditor

The University of Texas MD Anderson Cancer Center is one of the world's most respected centers devoted exclusively to cancer patient care, research, education and prevention. MD Anderson provides cancer care at several convenient locations throughout the Greater Houston Area and collaborates with community hospitals and health systems nationwide through MD Anderson Cancer Network®. U.S. News & World Report's "Best Hospitals"​ survey has ranked MD Anderson the nation's top hospital for cancer care. Every year since the survey began in 1990, MD Anderson has been named one of the top two cancer hospitals. The recognition reflects the passion of our 21,000 extraordinary employees and 1,000 volunteers for providing exceptional care to our patients and their families, and for realizing our mission to #EndCancer.

As a Nurse Defense Auditor 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 Nurse Defense Audit Coordinator position within the Hospital Billing & Collections 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 defense auditing.

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.