Clinical Nurse Coding Auditor (Part-time, Remote)

3 weeks, 3 days ago
Part-time
Senior
Operations
IntegrityM

IntegrityM

Integrity Management Services Offers a large variety of data integrity solutions including audits, fraud investigations, medical reviews, and more. Certified #WOSB providing expertise in #analytics, #audits #investigations #compliance #medicalreview #s...

Professional Services
51-250
Founded 2009

Description

  • Conduct prepayment claims reviews and post-payment audits to identify over-utilization, billing errors, and potential fraud.
  • Perform comprehensive provider record reviews to verify documentation and billing accuracy.
  • Analyze claims, performance data, and utilization trends to identify patterns and recommend process or policy improvements.
  • Assist in developing audit tools, policies, procedures, and educational materials to improve audit effectiveness.
  • Coordinate with service operations and other departments to provide claim review status updates and support corrective actions.
  • Support fraud investigators with clinical and medical review expertise.
  • Recommend modifications to medical policy based on audit findings and data analysis.
  • Serve as a mentor and resource to other nurse auditors.
  • Maintain accurate, compliant reporting aligned with payer regulations and reimbursement standards.

Requirements

  • Associate’s Degree in Nursing required.
  • Current, unrestricted Registered Nurse (RN) license in the applicable state(s).
  • Coding certification from AAPC or AHIMA, such as CPC, CIC, CDI, or an equivalent credential, is highly preferred.
  • Minimum 5 years of clinical nursing experience, preferably with hospital bill auditing or defense auditing exposure.
  • 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.
  • Strong foundation in auditing, accounting, and control principles.
  • Excellent written and verbal communication skills for reporting and provider engagement.
  • Proficiency with Microsoft Office and familiarity with audit tracking systems.

Interested in this position?

Apply directly on the company website

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