Auditor Clinical Validation Outpatient Specialty Clinical

Job description

Overview This auditing role will focus on Coding & Clinical Chart Validation for our Outpatient and Specialty audits. The ideal candidate for this position needs to have both a clinical (nurse) and a coding / auditing background focused on one of the following disciplines from a coding and billing perspective: SNF, IRF, Home Health, APC, ER, Diagnostics and Professional Service. This position is responsible for auditing outpatient/specialty claims and documenting the results of those audits. with a focus on clinical review, coding accuracy, medical necessity, and the appropriateness of treatment setting, and services delivered. Responsibilities: Audits Outpatient and Specialty Claims: - Utilizes medical chart coding principles and client specific guidelines in performance of medical audit activities with Outpatient (APC, PNPP), Pharmacy and/or Inpatient DRG claims. - Draws on advanced coding expertise and industry knowledge to substantiate conclusions. - Performs work independently, reviews and interprets medical records and applies in-depth knowledge of coding principles to determine potential billing/coding issues. Effectively Utilizes Audit Tools: - Utilizes advanced proficiency...