Pre-Payment Clinical Auditor (RN/Coder)

Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations.

Key responsibilities:

Allegation Triaging & Investigation: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services.

Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis.

Pre-Payment Clinical Review: Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized for payment.

Coding & Documentation Validation: Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.

Medical Necessity Assessment: Evaluate medical records against internal medical policies, prepare review summary as needed and work closely with Medical Directors

Prepare audit summaries and support referrals to Special Investigations Unit (SIU), Provider Performance, or Compliance teams when warranted.

Required Qualifications & Education:

Education: Nursing RN, active license

Core Coding Credentials: Must hold at least one active, nationally recognized coding certification:

AAPC: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC) or Certified Professional Medical Auditor (CPMA).

AHIMA: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), or Registered Health Information Technician/Administrator (RHIT/RHIA).

Experience: 5 years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, utilization management, or healthcare compliance, or related healthcare reimbursement functions, including medical record review and claims auditing.

Technical Expertise:

Demonstrated proficiency in CPT, HCPCS Level II, ICD-10-CM, and medical record documentation review.

Working knowledge of CMS reimbursement methodology, National Correct Coding Initiative (NCCI) edits, and applicable federal and state regulations.

Prefer:

Behavioral Health coding and auditing experience.

Knowledge of DSM-5 documentation requirements.

Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims.

Notes:

This is fully remote in any state except NY, CA, HI or AK