Offer summary

Qualifications:

Registered Nurse (RN) license in good standing., Minimum of 3 years of clinical nursing experience., At least 1 year of utilization or claims review experience., Strong knowledge of CPT/HCPCS coding and healthcare billing regulations..

Key responsibilities:

Perform retrospective reviews of outpatient medical claims for accuracy and medical necessity.

Apply coding standards and billing regulations to ensure proper reimbursement.

Review medical records using established guidelines and escalate quality issues.

Collaborate with medical directors and document audit findings for appeals and denials.

Job description

Job Title: RN Clinical Auditor – Claims and Coding Review (Outpatient Focus)

Location: Remote

Industry: National Managed Care Organization

Employment Type: Contract to Permanent

Pay: $40.00 per hour

Position Overview

A leading healthcare organization specializing in government-sponsored health plans is seeking an experienced Registered Nurse (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 code validation and regulatory compliance knowledge.

Key Responsibilities

Perform 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 proper claim reimbursement
Assess and audit claims related to:

Behavioral health and general outpatient services
Itemized bills, DRG validation, readmission reviews, and appropriate level of care

Review medical records using MCG/InterQual criteria, federal/state guidelines, and internal policies
Identify and document quality of care issues and escalate appropriately
Collaborate with Medical Directors for final determination on denials and clinical criteria application
Document audit findings in the system and provide 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
Active, 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 related to healthcare billing and audits
Strong understanding of CPT/HCPCS coding, medical documentation requirements, and outpatient reimbursement methodologies

Preferred Experience