Clinical Nurse Coding Auditor
Job Description:
- Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
- Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
- Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
- Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
- Support fraud investigators with medical review expertise to detect and address fraudulent activities.
- Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.
Requirements:
- Minimum
Associate’s Degree in Nursing
required;
- Current, unrestricted
Registered Nurse (RN)
license in applicable state(s).
- Certification in medical coding from
AAPC
or
AHIMA
(e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
- Minimum
5 years of clinical nursing experience
, preferably with exposure to hospital bill auditing or defense auditing.
- Strong knowledge of
provider manuals
,
reimbursement policies
, and
medical policy guidelines
.
- Prior experience with
healthcare fraud investigation
and auditing is highly preferred.
- Proficiency in CPT/HCPCS and ICD-10 coding, with a strong foundation in auditing, accounting, and control principles.
- Analytical and problem-solving skills with a keen attention to detail.
- Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
- Strong proficiency in Microsoft Office and familiarity with audit tracking systems.
Benefits: