Role Description We are seeking an experienced Clinical Nurse Auditor to join our Payment Integrity team. In this role, you will leverage your clinical expertise, medical coding proficiency, and auditing skills to identify, monitor, and analyze unusual utilization patterns and potential fraud by healthcare providers. You will conduct:

• Prepayment claims reviews
• Post-payment audits
• Comprehensive provider record reviews

to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices.

Qualifications

• 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

Requirements

• Meticulous, organized, and objective in analyzing claims and documentation
• Ethical and responsible, with a commitment to supporting the integrity of healthcare billing and reimbursement
• Able to work independently, stay current with rapidly changing healthcare regulations, and thrive in a fast-paced environment

Company Description