Clinical Nurse Coding Auditor

📋 Description

• Perform comprehensive medical evaluations through both prepayment claims assessment and post-payment audits to uncover potential over-utilization or fraudulent practices.

• Contribute to the development of audit resources, policies, procedures, and training materials to boost audit efficiency and uphold high standards in payment integrity.

• Act as a point of contact with service operations and other departments to provide updates on claims evaluations and coordinate necessary actions.

• Examine performance data to identify patterns and trends, collaborate with service operations to implement process enhancements, and suggest revisions to medical policy.

• Assist fraud investigators by providing medical review expertise to identify and mitigate fraudulent activities.

• Serve as a resource and mentor to fellow nurse auditors, fostering their professional growth and development in auditing practices.

⛳️ Requirements

• A minimum of **Associate’s Degree in Nursing** is required;

• Current, unrestricted **Registered Nurse (RN)** license in the relevant state(s).

• Certification in medical coding from **AAPC** or **AHIMA** (e.g., CPC, CIC, CDI, or equivalent) is strongly preferred.

• At least **5 years of clinical nursing experience**, preferably with experience in hospital bill auditing or defense auditing.

• In-depth knowledge of **provider manuals**, **reimbursement policies**, and **medical policy guidelines**.

• Previous experience in **healthcare fraud investigation** and auditing is highly preferred.

• Proficiency in CPT/HCPCS and ICD-10 coding, with a solid grounding in auditing, accounting, and control principles.

• Strong analytical and problem-solving abilities with meticulous attention to detail.

• Outstanding written and verbal communication skills for effective reporting and provider engagement.

• High proficiency in Microsoft Office and familiarity with audit tracking systems.

🏝️ Benefits

• Comprehensive health benefits package.

• Opportunities for professional development and continuing education.

• Flexible work arrangements.

• Competitive salary and performance-based incentives.