Clinical Provider Auditor (PHRN)

Private Advertiser; Taguig; On-site; PHP 260,000 - 420,000; Full time

Job summary

Private Advertiser is seeking a detail-oriented healthcare professional to support medical coding, claims review, and payment integrity activities. The role involves reviewing medical claims and clinical documentation to ensure coding accuracy, compliance with industry standards, and alignment with reimbursement guidelines.

The ideal candidate will have PHP RN license, CPC/CCS certification, and 1–2 years in medical coding or related fields, with strong analytical, investigative, and regulatory

Qualifications

• Must be a Philippine Registered Nurse (PHRN) with 1-2 years of hospital-based clinical experience.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification required.
• 1-2 years of experience in Medical Coding, Claims Review, Payment Integrity, Revenue Cycle Management, or a related healthcare field.
• Strong working knowledge of CPT, ICD-10-CM/PCS, HCPCS, and clinical documentation standards.
• Ability to identify coding errors, billing discrepancies, and potential Fraud, Waste, and Abuse (FWA) indicators.
• Strong analytical, investigative, and critical thinking skills.
• Knowledge of payer policies, reimbursement methodologies, regulatory requirements, and compliance standards.

Responsibilities

• Review medical claims and clinical documentation for coding accuracy.
• Ensure compliance with industry standards and reimbursement guidelines.
• Identify coding discrepancies, billing anomalies, and FWA indicators.
• Support accurate claim adjudication and payment processes.

Skills

Nurse qualification

Analytical thinking

Investigative skills

Payer policy knowledge

Education

PHRN license

CPC or CCS certification

Tools

CPT

ICD-10-CM/PCS

HCPCS

Job description

We are seeking a detail-oriented healthcare professional to support medical coding, claims review, and payment integrity activities. The role is responsible for reviewing medical claims and clinical documentation to ensure coding accuracy, compliance with industry standards, and alignment with reimbursement guidelines. Successful candidates will leverage their analytical and investigative skills to identify coding discrepancies, billing anomalies, and potential fraud, waste, and abuse (FWA) indicators while supporting accurate claim adjudication and payment processes.

Required Qualifications

• Must be a Philippine Registered Nurse (PHRN) with 1-2 years of hospital-based clinical experience.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification required.
• 1-2 years of experience in Medical Coding, Claims Review, Payment Integrity, Revenue Cycle Management, or a related healthcare field.
• Strong working knowledge of CPT, ICD-10-CM/PCS, HCPCS, and clinical documentation standards.
• Ability to identify coding errors, billing discrepancies, and potential Fraud, Waste, and Abuse (FWA) indicators.
• Strong analytical, investigative, and critical thinking skills.
• Knowledge of payer policies, reimbursement methodologies, regulatory requirements, and compliance standards.

Preferred

• Experience reviewing Medical-Surgical, High-Volume Laboratory, Radiology, and Ancillary Services claims.
• Experience in SIU, FWA, Payment Integrity, Provider Audit, or Investigative Audits.
  Knowledge of CMS regulations, provider contracts, and prepayment review guidelines.
• Experience in billing trend analysis, utilization reviews, and root cause analysis.
  Additional certifications (CPMA, RHIT, RHIA).
• Experience with CRAV, WGS, CIW, or similar claims review tools.
• Experience working with onshore and cross-functional stakeholders.