Medical Coder

EPITEC; Chicago (IL); Remote; USD 69,000 - 117,000; Full time

Job summary

EPITEC is seeking a Pre-Payment Clinical Auditor (RN/Coder) for a 6-month remote engagement in the United States. The role requires RN licensure, active coding credentials, and 5+ years in clinical auditing and coding.

You will review complex claims prior to payment, validate documentation against CPT/HCPCS/ICD-10, assess medical necessity, and coordinate with Medical Directors and SIU as needed.

Qualifications

• RN with active license is required.
• At least 5 years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, utilization management, or healthcare compliance.
• Proficiency with CPT, HCPCS Level II, ICD-10-CM/PCS and medical record documentation review.

Responsibilities

• Allegation triaging and investigation of third-party referrals, compliance tips, and external fraud allegations.
• Identify fraud, waste, abuse, billing irregularities through medical record review and claims analysis.
• Pre-payment clinical review of high-dollar or complex medical records before finalizing payment.
• Audit documentation to ensure alignment with CPT/HCPCS/ICD-10-CM/ICD-10-PCS and Official Coding Guidelines.
• Evaluate medical records against internal policies; collaborate with Medical Directors.
• Prepare audit summaries and support referrals to SIU, Provider Performance, or Compliance teams when warranted.

Skills

Clinical auditing

Medical coding

Regulatory compliance

Medical record review

Education

Active RN license

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

Job description

Job Title: Pre-Payment Clinical Auditor (RN/Coder)

Contract Duration: 6 months, possible extension

Work Arrangement: Remote

Summary

Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations.

Key Responsibilities

• Allegation Triaging & Investigation: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services.
• Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis.
• Pre-Payment Clinical Review: Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized for payment.
• Coding & Documentation Validation: Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.
• Medical Necessity Assessment: Evaluate medical records against internal medical policies, prepare review summary as needed and work closely with Medical Directors
• Prepare audit summaries and support referrals to Special Investigations Unit (SIU), Provider Performance, or Compliance teams when warranted.

Required Qualifications & Education

• Education: Nursing RN, active license
• Core Coding Credentials: Must hold at least one active, nationally recognized coding certification:
  • AAPC: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC) or Certified Professional Medical Auditor (CPMA).
  • AHIMA: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician-based (CCS-P), or Registered Health Information Technician/Administrator (RHIT/RHIA).
• Experience: 5 years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, utilization management, or healthcare compliance, or related healthcare reimbursement functions, including medical record review and claims auditing.

Technical Expertise

• Demonstrated proficiency in CPT, HCPCS Level II, ICD-10-CM, and medical record documentation review.
• Working knowledge of CMS reimbursement methodology, National Correct Coding Initiative (NCCI) edits, and applicable federal and state regulations.

Prefer

• Behavioral Health coding and auditing experience.
• Knowledge of DSM-5 documentation requirements.
• Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims.