Medical Coder

VIVA; United States; Remote; USD 90,000 - 120,000; Full time

Benefits offered by this job

Remote work

Job summary

VIVA is seeking a Pre-Payment Clinical Auditor (RN/Coder) to investigate complex healthcare claims prior to payment. The role blends advanced coding (ICD-10, CPT, HCPCS) with investigative scrutiny of medical records for alignment with regulations and medical necessity.

Responsibilities include triaging referrals, identifying fraud patterns, performing pre-payment reviews, and coordinating with SIU or Compliance teams as needed. RN licensure and multiple coding credentials are required.

Qualifications

• RN license required.
• Active nursing license in good standing.
• Experience auditing and reviewing medical records for coding accuracy and medical necessity.

Responsibilities

• Allegation triaging & investigation: analyze third-party referrals and external tips to identify billing patterns and suspect providers.
• Identify fraud, waste, abuse, and non-compliance through claims analysis and medical record review.
• Pre-payment clinical review: conduct comprehensive reviews of high-dollar or complex records before payment.
• Coding & documentation validation: ensure alignment with CPT, HCPCS, ICD-10-CM/PCS and official guidelines.
• Medical necessity assessment: evaluate records against internal policies and collaborate with Medical Directors.
• Prepare audit summaries and support referrals to SIU, Provider Performance, or Compliance teams when warranted.

Skills

Clinical auditing

Medical coding

Investigation

Regulatory knowledge

Education

RN nursing license

Tools

CPC

COC

CIC

CPMA

CCS

CCS-P

RHIT/RHIA

Job description

This is fully remote in any state except NY, CA, HI or AK

Pre-Payment Clinical Auditor (RN/Coder)

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.

Notes:

This is fully remote in any state except NY, CA, HI or AK

VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status