Clinical Documentation & Utilization Nurse Auditor

It's rewarding to be on a team of people that truly believe in making an impact! 

We are committed to building the best primary care environment for patients and are seeking healthcare enthusiasts to join us.

Job Summary

The Clinical Documentation & Utilization NurseAuditor is responsible for conducting comprehensive clinical audits to evaluate the accuracy, quality, and compliance of patient care documentation, utilization practices, and adherence to evidence-based clinical pathways. This role focuses heavily on chronic condition management (including COPD, Heart Failure, Diabetes, Metabolic syndrome, and Dementia) and compliance with CMS regulations, particularly Annual Wellness Visit (AWV) requirements.

The Nurse Clinical Auditor works independently while collaborating with interdisciplinary clinical, care management, and leadership teams to identify care gaps, ensure regulatory compliance, and support quality improvement initiatives that enhance patient outcomes and organizational performance.

Essential Duties & Responsibilities

• Clinical Documentation & Quality Auditing
• Conduct detailed audits of patient charts and clinical documentation to ensure accuracy, completeness, and compliance with CMS guidelines and organizational standards.
• Validate documentation related to chronic condition management plans, interventions, and outcomes.
• Support Clinical Documentation Improvement (CDI) initiatives to enhance care quality and audit readiness.
• Clinical Pathway & Care Management Evaluation
• Assess adherence to evidence-based clinical pathways for COPD, Heart Failure , Diabetes,Metabolic Syndrome  and Dementia.
• Identify deviations from established standards of care and provide actionable feedback to improve care consistency and outcomes.
• Monitor patient charts concurrently during treatment to evaluate appropriateness of care delivery.
• Annual Wellness Visit (AWV) Compliance
• Review and audit Annual Wellness Visits to ensure proper application of CMS guidelines, including preventive screenings, risk assessments, and required documentation elements.
• Ensure accurate coding and documentation for all AWV components to support compliance and reimbursement.
• Utilization Management & Resource Optimization
• Conduct utilization reviews to determine whether patients are receiving care appropriate to their illness or condition.
• Analyze utilization patterns to identify overutilization or underutilization of services.
• Review treatment plans, authorization status, and insurer approvals to ensure appropriate and cost-effective resource use.
• Consult with physicians and care teams as needed to clarify clinical decisions and documentation.
• Quality Improvement & Reporting
• Prepare detailed audit reports outlining findings, trends, risks, and actionable recommendations.
• Collect, compile, and report data in accordance with internal policies and regulatory requirements.
• Participate in quality assurance, quality improvement, and staff education initiatives.
• Contribute insights and findings to senior and executive leadership as needed.

Education & Experience

• Active Registered Nurse (RN) license required
• Bachelor’s degree in Nursing (BSN) preferred
• Minimum of 5 years of clinical nursing experience, preferably in acute care, chronic care, or population health settings
• At least 2 years of experience in utilization management, case management, clinical auditing, or quality assurance
• Demonstrated experience managing or auditing care for chronic conditions such as COPD, CHF, Diabetes, and Dementia
• Contributes to moderately complex projects with a high degree of independence.
• Works collaboratively across clinical and operational teams.

Education Requirements

Education Level

Discipline

Required

Bachelor's Degree

Nursing

Knowledge, Skills & Proficiencies

• Strong knowledge of CMS regulations, AWV requirements, and clinical documentation standards
• Proficiency in utilization management and quality audit processes
• Experience with clinical documentation and EMR systems (e.g., eClinicalWorks or similar)
• Understanding of medical coding principles and payer authorization processes
• Excellent analytical, communication, and report-writing skills
• Ability to work independently while collaborating effectively with interdisciplinary teams

Physical Requirements

This position works under usual office conditions. The associate is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing. 

Travel Requirements

Amount of Expected Travel

Details

Yes

0-25%

Flexibility to travel to clinical sites as needed

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

Join our team that is making a difference!

Please see Cano Health’s Notice of E-Verify Participation and the Right to Work post here