Clinical Nurse Coding Auditor (Part-time, Remote)

Job description

Job Title: Clinical Nurse Auditor – Payment Integrity Job Summary: We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct prepayment claims reviews, post-payment audits, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a Registered Nurse (RN) with coding certifications such as CPC (Certified Professional Coder), CIC (Certified Inpatient Coder), CDI (Clinical Documentation Improvement), or a similar credential, through AAPC or AHIMA . Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential. How You Will Make an Impact - Investigations and Audits : Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities. - Tool and Policy Development : Assist in the creation of audit tools, poli...