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:

• Experience with behavioral health claims review

• Knowledge of MCG/InterQual guidelines

• Prior experience working with health plans or managed care organizations

• Experience in reviewing appeal documentation and making clinical determinations

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