Clinical Nurse Auditor – Payment Integrity - Remote

Overview

An experienced Clinical Nurse Auditor is needed to join the Payment Integrity team, focusing on identifying and analyzing unusual utilization patterns and potential fraud by healthcare providers.

In Short

• Conduct prepayment claims reviews and post-payment audits.
• Analyze provider record reviews to ensure accurate billing and compliance.
• Utilize clinical expertise and medical coding proficiency.
• Identify potential over-utilization or fraudulent activities.
• Assist in developing audit tools and educational materials.
• Collaborate with service operations for claims review updates.
• Mentor other nurse auditors in audit practices.
• Support fraud investigators with medical review expertise.
• Analyze performance data for process improvements.
• Maintain high standards in payment integrity.

Requirements

• Registered Nurse (RN) with coding certifications (CPC, CIC, CDI).
• Knowledge of commercial insurance, Medicare, and Medicaid.
• Experience in medical coding and auditing.
• Strong analytical skills.
• Excellent communication and collaboration skills.
• Ability to mentor and support peers.

Benefits

• Flexible part-time schedule.
• Opportunity to work remotely.
• Professional growth and development opportunities.
• Engagement in meaningful work within healthcare.
• Collaborative team environment.