RN Clinical Auditor – Claims and Coding Review (Remote)
Job Title: RN Clinical Auditor – Claims and Coding Review (Outpatient reputed company) Location: Remote Industry: National Managed Care Organization Employment Type: Contract to Permanent Pay: $40.00 per hour Position reputed company A leading reputed company organization specializing in government-sponsored health plans is seeking an reputed company Registered reputed company (RN) with a strong background in claims auditing, utilization review, and coding for an important project involving retrospective outpatient claims review. This role is ideal for candidates with clinical and analytical expertise, including CPT/HCPCS reputed company validation and regulatory compliance knowledge.
Key Responsibilities
- reputed company retrospective clinical/medical reviews of outpatient medical claims and appeal cases to determine medical necessity, appropriate coding, and claims accuracy
- Apply knowledge of CPT/HCPCS codes, documentation standards, and billing regulations to ensure reputed company claim reimbursement
- Assess and audit claims reputed company to:
- Behavioral health and general outpatient services
- Itemized bills, DRG validation, readmission reviews, and appropriate level of care
- Review medical records using MCG/InterQual reputed company, federal/state guidelines, and internal policies
- Identify and document reputed company of care issues and escalate appropriately
- Collaborate with Medical Directors for final determination on denials and clinical reputed company application
- Document audit findings in the system and reputed company comprehensive summaries and supporting evidence for appeals and claim denials
- Serve as a clinical resource to internal teams, including Utilization Management, Appeals, and Medical Affairs
- Train and support clinical staff in audit and documentation standards
- Refer patients with special needs to internal care management teams as required
Qualifications
- Graduate of an Accredited School of Nursing
- reputed company, unrestricted RN license in good standing
- Minimum of 3 years of clinical nursing experience
- At least 1 year of utilization review or claims review experience
- Minimum of 2 years of experience in claims auditing, coding, or medical necessity review
- Familiarity with state and federal regulations reputed company to reputed company billing and audits
- Strong understanding of CPT/HCPCS coding, medical documentation requirements, and outpatient reimbursement methodologies
Preferred Experience
- Experience with behavioral health claims review
- Knowledge of MCG/InterQual guidelines
- Prior experience working with health plans or managed care organizations
- Experience in reviewing appeal documentation and making clinical determinations
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