RN Clinical Auditor – Claims and Coding Review (Remote)

This a FullRemote job, the offer is available from: United States 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 determinationsThis offer from "Morgan Stephens" has been enriched by Jobgether.com and got a 74% flex score.Apply tot his job