RN Clinical Auditor Claims and Coding Review (Remote)

This a FullRemote job, the offer is available from: United StatesJob Title: RN Clinical Auditor Claims and Coding Review (Outpatient Focus)Location: RemoteIndustry: National Managed Care OrganizationEmployment Type: Contract to PermanentPay: $40.00 per hourPosition OverviewA 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 ResponsibilitiesPerform retrospective clinical/medical reviews of outpatient medical claims and appeal cases to determine medical necessity, appropriate coding, and claims accuracyApply knowledge of CPT/HCPCS codes, documentation standards, and billing regulations to ensure proper claim reimbursementAssess and audit claims related to:Behavioral health and general outpatient servicesItemized bills, DRG validation, readmission reviews, and appropriate level of careReview medical records using MCG/InterQual criteria, federal/state guidelines, and internal policiesIdentify and document quality of care issues and escalate appropriatelyCollaborate with Medical Directors for final determination on denials and clinical criteria applicationDocument audit findings in the system and provide comprehensive summaries and supporting evidence for appeals and claim denialsServe as a clinical resource to internal teams, including Utilization Management, Appeals, and Medical AffairsTrain and support clinical staff in audit and documentation standardsRefer patients with special needs to internal care management teams as requiredQualificationsGraduate of an Accredited School of NursingActive, unrestricted RN license in good standingMinimum of 3 years of clinical nursing experienceAt least 1 year of utilization review or claims review experienceMinimum of 2 years of experience in claims auditing, coding, or medical necessity reviewFamiliarity with state and federal regulations related to healthcare billing and auditsStrong understanding of CPT/HCPCS coding, medical documentation requirements, and outpatient reimbursement methodologiesPreferred ExperienceExperience with behavioral health claims reviewKnowledge of MCG/InterQual guidelinesPrior experience working with health plans or managed care organizationsExperience in reviewing appeal documentation and making clinical determinationsThis offer from "Morgan Stephens" has been enriched by Jobgether.com and got a 74% flex score.Apply tot his job