OVERVIEW
What is a Nurse Auditor?
A nursing audit consists of collecting information from nursing reports, medical notes and other patient care records to help assess the quality of care. Therefore, a nurse auditor is responsible for managing medical records in healthcare settings and insurance companies. They make sure that everything is following correct processes and systems—from quality of care and medical necessity to regulations, complaints, and insurance claim coding. While a lot of people get into nursing to provide healthcare for their patients, nurse auditors can gain satisfaction from providing patients with financial care and making sure they get everything they’re entitled to.
RESPONSIBILITIES
What Does a Nurse Auditor Do?
A nurse auditor’s job is to oversee medical records and make sure that everything is coded correctly, ensuring optimal outcomes for both the patient and the hospital. Below is a summary of just some of the day-to-day tasks they might be asked to perform.
Managing medical records and insurance claims. The cornerstone of a nurse auditor’s job is managing the medical records at their place of employment. They’ll be analyzing files and running them through rigorous checks: was the procedure undertaken by the patient a medical necessity? Did the patient receive the correct quality of care that they should have? Have they filed the insurance claim correctly? And will that claim be covered or not?
Ensuring accuracy and compliance with various regulations. Accuracy of medical records is paramount—and in a chaotic environment like a hospital, people can easily make mistakes. That’s why a nurse auditor must go through everything with a fine-toothed comb and ensure a high level of accuracy. Plus you’ll have to make sure that everything complies with hospital, state, and insurance regulations.
Appeals and billing. Medical billing is a complicated process. It all depends on the patient, the insurance, and the procedure. Nurse auditors are responsible for ensuring that this complicated process is done correctly. Plus any errors in medical coding can mean money lost by the hospital. So working accurately, staying up to date on coding rules, and verifying insurance policies will keep this extra cost to a minimum. And if something does go wrong, you’ll be the one they call upon to sort it out.
These and other responsibilities help head nurses thrive in a variety of medical settings. Especially in urgent or emergency medical environments, it’s important that head nurses understand the roles of all their staff as well as how to correctly fulfill all responsibilities.
EDUCATION & BEST DEGREES
How Do I Become a Nurse Auditor?
Step One: Become a Registered Nurse.
The first thing you’ll have to do is become a Registered Nurse (RN). You’ll need a nursing diploma, associate degree, or a bachelor’s degree in nursing in order to become licensed in your state. If you already have a nursing diploma or an associate degree in nursing, you might want to apply for an RN-to-BSN, which allows working nurses to gain their bachelor’s faster. A BSN is usually especially valuable for those who want to move beyond being a registered nurse into other roles, like nurse auditing. So pursuing your BSN is key to progression.
Step Two: Obtain Medical Coding and Experience.
While there’s no specific degree required to be a nurse auditor, being an RN is a must; and BSN can be extremely helpful in ensuring you stand out from other candidates. And once you’ve got that, you’ll need to gain some experience with coding and billing in a healthcare setting. You can do this at a hospital, hospice, or a medical clinic. You’ll want around one year of experience before you begin the certification process and become a nurse auditor.
Step Three: Gain Nurse Auditor Certification.
The final step is getting certified. While there are several routes you can take, the American Academy of Professional Coders (AAPC) offers training to help you pass the exam, additional study materials, and lots of advice. The exam covers topics such as chart audits, third-party reimbursement, and medical fraud. And once you’ve successfully obtained your certification, you’ll be ready to start your new career as a nurse auditor.
Best Degrees for a Nurse Auditor
Health & Nursing
Nursing (Prelicensure) – B.S.
A one-of-a-kind nursing program that prepares you to be an RN and a...
A one-of-a-kind nursing program that prepares you to be an RN and a baccalaureate-prepared nurse:
- Locations: Due to in-person clinical requirements, students must be full time residents of FL, ID, IN, IA, KS, KY, NV, NM, NC, OH, OK, SC, TN, TX, UT to enroll in this program. The coursework in this program is offered online, but there are in-person requirements.
- Tuition: $6,430 per 6-month term for the first 4 terms of pre-nursing coursework and $8,755 per 6-month term for the remaining 4 terms of clinical nursing coursework.
- Time: This program has a set pace and an expected completion time of 4 years. Certain coursework may be accelerated to finish faster.
- WGU offers the prelicensure program in areas where we have partnerships with healthcare employers to provide practice sites and clinical coaches to help teach you and inspire you on your path to becoming a nurse.
- If you don't live in one of our prelicensure states or don't qualify to apply, consider getting our Bachelor's in Health and Human Services instead. This degree allows you to work inside the healthcare industry, while also working directly with patients who need help.
Skills for your résumé that you will learn in this program:
- Community Health
- Women's and Children's Nursing
- Pathology
- Physiology
- Research
Health & Nursing
Nursing (RN-to-BSN Online) – B.S.
An online BSN degree program for registered nurses (RNs) seeking the added...
An online BSN degree program for registered nurses (RNs) seeking the added theoretical depth, employability, and respect that a bachelor's degree brings:
- Time: 61% of graduates finish within 20 months.
- Tuition: $4,685 per 6-month term.
- Courses: 23 total courses in this program.
- Transfers: Students can transfer up to 90 credits.
Skills for your résumé that you will learn in this program:
- Healthcare Policy and Economics
- Information Technology in Nursing Practice
- Anatomy and Physiology
- Applied Healthcare Statistics
If you don't currently have an RN and don't qualify for your nursing prelicensure program, consider getting our Bachelor's in Health and Human Services instead. This degree allows you to work inside the healthcare industry in a unique way.
Health & Nursing
Nursing – Leadership & Management (RN-to-MSN) – M.S.
This program for RNs includes a BSN component and is a substantial leap...
This program for RNs includes a BSN component and is a substantial leap toward becoming a nurse leader.
- Time: 62% of RN-to-MSN grads finish within 37 months.
- Tuition: $4,685 per 6-month term during undergraduate portion and $4,795 per 6-month term during graduate portion.
- Courses: 32 total courses in this program.
Skills for your résumé you will learn in this program:
- Quality Outcomes in a Culture of Value-Based Nursing Care
- Nursing Leadership and Management
- Advanced Pathopharmacological Foundations
- Informatics for Transforming Nursing Care
If you're driven to lead, this online nursing degree will provide you everything needed to make that career a reality. This program is ideal for current RNs who are interested in earning both their BSn and MSN in an accelerated program.
Compare degrees
This program is not the only degree WGU offers designed to create leaders in the field of healthcare. Compare our health leadership degrees.
Health & Nursing
Nursing – Leadership & Management (BSN-to-MSN) – M.S.
For registered nurses with a bachelor's degree who are ready for...
For registered nurses with a bachelor's degree who are ready for additional career opportunities.
- Time: 61% of grads finish within 23 months
- Tuition: $4,795 per 6-month term
- Courses: 15 total courses in this program
This program is ideal for current RNs who have a BSN and are ready for the next step in their education.
Skills for your résumé you will learn in this program:
- Quality Outcomes in a Culture of Value-Based Nursing Care
- Nursing Leadership and Management
- Advanced Pathopharmacological Foundations
- Informatics for Transforming Nursing Care
Compare degrees
This program is not the only degree WGU offers designed to create leaders in the field of healthcare. Compare our health leadership degrees.
Health & Nursing
Nursing Leadership and Management – Post-Master's Certificate
A certificate for registered nurses with a master's degree in nursing who...
A certificate for registered nurses with a master's degree in nursing who are ready for greater responsibility in a leadership and management role.
- Time: Students typically finish this program in 12 months.
- Tuition: $4,795 per 6-month term. The cost to sit for the NAHQ Certified Professional in Healthcare Quality (CPHQ) exam is included in tuition.
- Courses: 8 total courses in this program.
Skills for your résumé that you will learn in this program:
- Strategic Planning
- Resource Management
- Business Case Analysis
- Evaluating Healthcare Improvements
What Is the Projected Job Growth?
6%
From 2022 to 2032, employment for registered nurses is expected to grow 6%. This projected growth rate is well above the average across all occupations. Aging populations are largely behind the forecasted increase in required healthcare services. Head nurses in particular will be needed to educate nurses on any issues that patients might be facing.
SKILLS
What Skills Does a Nurse Auditor need?
A nurse auditor needs a wide array of skills to thrive in the workplace. First, they must be highly-trained registered nurses with a deep understanding of the latest medical practices and insurance systems. And on top of that, they’re auditors with an eye for detail and numbers, making sure no mistakes slip by them. This requires:
- Great communication skills
- Knowledge of medical coding systems
- Attention to detail
- Keen understanding of insurance plans
- The ability to work as part of a team
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