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An elevated approach to program analysis.
Clinical Nurse Coding Auditor
Location
Virginia
Posted
30 days ago
Salary
0
Seniority
Senior
Job Description
Clinical Nurse Coding Auditor
Integrity Management Services, Inc.
• Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities. • Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity. • Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed. • Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy. • Support fraud investigators with medical review expertise to detect and address fraudulent activities. • Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.
Job Requirements
- Minimum **Associate’s Degree in Nursing** required;
- Current, unrestricted **Registered Nurse (RN)** license in applicable state(s).
- Certification in medical coding from **AAPC** or **AHIMA** (e.g., CPC, CIC, CDI, or equivalent) is highly preferred.
- Minimum **5 years of clinical nursing experience**, preferably with exposure to hospital bill auditing or defense auditing.
- 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, with a strong foundation in auditing, accounting, and control principles.
- Analytical and problem-solving skills with a keen attention to detail.
- Exceptional written and verbal communication skills for clear and effective reporting and provider engagement.
- Strong proficiency in Microsoft Office and familiarity with audit tracking systems.
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