Medical Compliance Auditor (RN) - Health Plan - Bellaire, TX

Position: Medical Compliance Auditor (RN) - Health Plan - Bellaire, TX

Job ID: 139834

Location: US-TX-Houston

Department: Controls & Compliance

Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 13,000 dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at


We are searching for a Medical Compliance Auditor - someone who works well in a fast-paced hospital setting. In this position, you’ll review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. This process includes clinical judgment, utilization review, application of product benefits, understanding of regulatory requirements for Medicaid managed care and fraud and abuse, and verification of medical necessity utilizing nationally recognized criteria. 



Think you’ve got what it takes?

Responsibilities :

  • Utilizes established criteria to appropriately review billed services within established timeframe required
  • Consults with medical directors and clinical staff regarding patient’s history and current care needs and whether services billed were appropriate
  • Refers case failing medical necessity criteria to the Special Investigations Unit (SIU) Director and SIU Workgroup for review and a recommendation for action
  • Telephonic follow up with the provider’s office to request additional information as needed
  • Completes timely entry of information into electronic file including a chart with detailed findings of the review and a report summarizing the results of the audit
  • Researches Medicaid/CHIP Program requirements, benefits, CPT coding guidance and any other industry standard guidelines that will assist in performing the clinical review of the medical claim appeal
  • Reviews the medical record submitted with the medical claim appeal to determine if the documentation supports the service billed by the provider and the service is appropriately coded
  • Uses clinical and medical coding judgement to approve or deny the medical claim appeal
  • Collaborates with other subject matter experts in the health plan to better understand any clinical or coding issues on an as-needed basis
  • Ensures the timeliness of all education and recoupment letters within the required timelines
  • Reviews all education and recoupment letters for appropriate verbiage and accuracy of the stated criteria that was met or not met in performance of the audit
  • Sends letters to the provider and communicates the results to Provider Relations and Claims Dept. (if a recoupment) to ensure a collaborative resolution
  • Ensures copies of education and recoupment letters are appropriately distributed to all parties involved
  • Notifies providers of denied services through written correspondence with education attached and follows up with provider verbally if requested by the provider
  • Collaborates with all disciplines within the health plan to meet goals and objectives
  • Perform Clinical Review and make recommendation on Audit Pass/Fail


  • Bachelor of Science in Nursing (BSN)
  • Registered Nurse (RN) license granted by the Texas State Board of Nursing
  • Two (2) years of RN, medical auditing, and/or managed care experience
  • Highly motivated and able to work independently
  • Must be a team player that is able to effectively collaborate with team members and outside departments
  • Knowledge of pediatrics is preferred

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