Medical Compliance Auditor

Position: Medical Compliance Auditor

Job ID: 158147

Location: US-TX-Houston


Talent Area: Registered Nurse

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a-5p

About Texas Children's Hospital

Texas Children’s Health Plan   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 14,000+ dedicated team members, visit for career opportunities. You can also learn more about our amazing culture at   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.


We are searching for a Medical Compliance Auditor – someone who works well in a fast-paced managed care setting. In this position, you will review and approve or deny medical claim appeals and perform clinical audits of medical records submitted in support of services billed by providers. You must have the ability to have 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. 


We are looking for someone with a nursing background, previous experience with managed care, and experience in auditing or utilization management. 


Think you have what it takes?

Responsibilities :

Job Duties & Responsibilities


  • Perform Clinical and Coding Review on Medical Claim Appeals 
  • Reviews documentation in records to determine appropriate assigned ICD-10-CM, ICD-10-PCS, CPT and HCPCS codes.
  • Collaborates with all disciplines within the health plan to meet goals and objectives.
  • Communicates with and provides feedback to the claims examiners for accurate claims appeal processing.
  • Ongoing assessment for quality indicators and concerns
  • Identifies potential quality of care issues documents in the electronic file, and discusses with SIU team
  • Quality issues may be referred to the Quality Department for further follow up
  • Reviews accuracy of sequenced diagnosis and procedures to generate appropriate DRGs for billing in accordance with the Coding Guidelines based on the type of coding.
  • Utilizes the encoder or coding books to correctly assign all appropriate ICD-10-CM, ICD-10-PCS, CPT and HCPCS codes for diagnosis and procedures.


Being fully vaccinated against COVID-19 is required for all employees at Texas Children’s, unless approved for a medical or religious exemption.

Skills & Requirements

  • Bachelor's Degree in Nursing
  • 2 years RN experience
  • 2 years medical auditing, DRG Outlier Review, managed care expertise, and/ or Utilization review experience
  • BLS – Cert-Basic Life Support issued by the American Heart Association
  • Experience with DRG Grouper
  • RN - Lic-Registered Nurses by Texas State Board of Nursing
  • 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 a plus
  • Excellent verbal and written skills, good computer skills (Microsoft word and excel), and excellent clinical judgment and reasoning skills

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