Medical Claims Auditor & Coding Specialist

W3R Consulting; United States; Sur place; USD 90 000 - 130 000; Plein temps

Résumé du poste

W3R Consulting is seeking an experienced Healthcare Claims Auditor with an active RN license and coding credentials. You will conduct pre-payment reviews, validate documentation against CPT/HCPCS/ICD-10-CM, and assess medical necessity across complex claims.

The role requires strong analytical skills and familiarity with CMS rules, NCCI edits, and state/federal regulations. Prior SIU or compliance collaboration is a plus.

Qualifications

• RN license active and required
• 5 years of combined experience in clinical auditing, medical coding, or related healthcare compliance
• Must hold at least one active coding certification (CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA)
• Proficiency in CPT, HCPCS Level II, ICD-10-CM/PCS and medical record documentation review

Responsabilités

• Triaging and investigating third-party referrals, tips, and external fraud allegations to identify billing patterns
• Identify fraud, waste, abuse, and non-compliance through medical record review and claims analysis
• Pre-payment clinical review of high-value or complex records before payment
• Audit clinical documentation for alignment with coding guidelines and medical necessity
• Prepare summaries and support referrals to SIU or Compliance when warranted

Connaissances

Attention to detail

Analytical thinking

Regulatory knowledge

Formation

RN license

CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA

Outils

CPT

HCPCS Level II

ICD-10-CM/ICD-10-PCS

Description du poste

W3R Consulting is seeking an experienced Healthcare Claims Auditor with an active RN license and coding credentials. You will conduct pre-payment reviews, validate documentation against CPT/HCPCS/ICD-10-CM, and assess medical necessity across complex claims.

The role requires strong analytical skills and familiarity with CMS rules, NCCI edits, and state/federal regulations. Prior SIU or compliance collaboration is a plus.