Integrity Management Services, Inc.

Clinical Nurse Coding Auditor, Part-time

Integrity Management Services, Inc.

part-time

Posted on:

Location Type: Remote

Location: Virginia • United States

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About the role

  • **Job Title:** **Clinical Nurse Auditor – Payment Integrity**
  • **Job Summary****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, and comprehensive provider record reviews to ensure accurate billing, compliance with payer regulations, and integrity in reimbursement practices. This position requires a **Registered Nurse (RN)** with coding certifications such as **CPC** (Certified Professional Coder), **CIC** (Certified Inpatient Coder), **CDI** (Clinical Documentation Improvement), or a similar credential, through **AAPC** or **AHIMA**. Knowledge of commercial insurance plans, Medicare, and Medicaid programs is essential.
  • **How You Will Make an Impact **
  • - **Investigations and Audits**: Conduct in-depth medical reviews through prepayment claims review and post-payment auditing to identify potential over-utilization or fraudulent activities.
  • - **Tool and Policy Development**: Assist in the creation of audit tools, policies, procedures, and educational materials to enhance audit effectiveness and maintain high standards in payment integrity.
  • - **Cross-Departmental Collaboration**: Serve as a liaison with service operations and other departments to provide status updates on claims reviews and coordinate actions as needed.
  • - **Data Analysis and Trending**: Analyze performance data to identify patterns and trends, collaborate with service operations to address process improvements, and recommend modifications to medical policy.
  • - **Fraud Detection Support**: Support fraud investigators with medical review expertise to detect and address fraudulent activities.
  • - **Mentorship**: Act as a resource and mentor to other nurse auditors, supporting their professional growth and development in audit practices.

Requirements

  • **Qualifications**
  • - **Education**:
  • - Minimum **Associate’s Degree in Nursing** required;
  • - **Licensure & Certification**:
  • - 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.
  • - **Experience**:
  • - 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.
  • - **Skills**:
  • - 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.
  • **Preferred Traits**
  • - 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.
Applicant Tracking System Keywords

Tip: use these terms in your resume and cover letter to boost ATS matches.

Hard Skills & Tools
medical codingauditingCPT codingHCPCS codingICD-10 codingdata analysisfraud detectionreimbursement policiesprovider manualshealthcare fraud investigation
Soft Skills
analytical skillsproblem-solving skillsattention to detailwritten communicationverbal communicationorganizational skillsmentorshipindependenceethical responsibilityadaptability
Certifications
Registered Nurse (RN)CPCCICCDIAAPC certificationAHIMA certification