Auditor Clinical Validation Outpatient Specialty Clinical
New
Based in the United StatesFull-TimeMiddle
SalaryHourly rate equivalent to approximately $95,000 annually
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Job Details
- Experience
- 5–7 years
- Required Skills
- HIPAA
Requirements
- Associate or Bachelor’s degree in Nursing with an active and unrestricted clinical license.
- Active coding certification (such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT).
- Strong command of ICD-10, CPT, HCPCS coding systems and official coding guidelines.
- 5–7 years of experience in clinical medical record coding, auditing, or utilization review.
- Strong understanding of HIPAA regulations, CMS requirements, and payer reimbursement policies.
- Strong analytical skills with the ability to interpret complex medical records and evaluate clinical documentation.
- Excellent written and verbal communication skills.
- Ability to work independently in a remote, detail-heavy, compliance-focused environment.
- Strong attention to detail and organizational discipline.
Responsibilities
- Perform detailed outpatient and specialty claims audits by reviewing medical records and applying clinical coding principles to validate billing accuracy, medical necessity, and treatment appropriateness across multiple care settings.
- Use advanced audit systems and coding tools to document findings, ensure accurate claim entry, and support consistent application of client-specific guidelines and regulatory standards.
- Maintain defined productivity, quality, and accuracy benchmarks while independently managing assigned audit workloads.
- Identify complex coding discrepancies, evaluate claims outside standard audit scope, and contribute insights for potential recovery opportunities.
- Collaborate on process improvement by recommending enhancements to audit methodologies, tools, and workflows.
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