Medical Coder/ RN

Pyramid Consulting; Chicago (IL); Remote; USD 55,000 - 79,000; Full time

Benefits offered by this job

Health insurance

401(k) plan

Paid sick leave

Job summary

Pyramid Consulting is seeking a Medical Coder/RN for a 06+ month contract, remotely in the US. Must have 5+ years in clinical auditing, medical coding, and healthcare compliance, with active RN license and coding credentials (CPC/COC/CCS/CPMA or CCS-P/RHIT/RHIA).

Responsibilities include decoding referrals, auditing mental health claims, and collaborating with Medical Directors on audit summaries and SIU referrals. Strong DSM-5 knowledge required.

Qualifications

• 5+ years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, or healthcare compliance.
• Active Nursing RN license.
• At least one active coding credential (CPC/COC/CCS/CPMA or CCS-P/RHIT/RHIA).
• Experience in Behavioral Health coding and auditing.
• Knowledge of DSM-5 documentation requirements.

Responsibilities

• Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns and suspect providers.
• Identify potential fraud, waste, abuse, and billing irregularities through thorough medical record reviews and claims analysis.
• Perform comprehensive clinical and technical reviews of high-dollar or complex medical records before claims are finalized for payment.
• Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.
• Evaluate medical records against internal medical policies and prepare review summaries as needed.
• Collaborate closely with Medical Directors and prepare audit summaries to support referrals to SIU or Compliance teams when warranted.

Skills

Clinical auditing

Medical coding

Fraud detection

Claims analysis

Healthcare compliance

DSM-5 knowledge

Education

RN license

AAPC/AHIMA coding credentials

Job description

Medical Coder/ RNImmediate need for a talented Medical Coder/ RN. This is a 06+ Months Contract opportunity with long-term potential and is located in US (Remote). Please review the job description below and contact me ASAP if you are interested. Job ID:26-33958 Pay Range: $48.5/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities:

• Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns and suspect providers.
• Identify potential fraud, waste, abuse, and billing irregularities through thorough medical record reviews and claims analysis.
• Perform comprehensive clinical and technical reviews of high-dollar or complex medical records before claims are finalized for payment.
• Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.
• Evaluate medical records against internal medical policies and prepare review summaries as needed.
• Collaborate closely with Medical Directors and prepare audit summaries to support referrals to Special Investigations Unit (SIU) or Compliance teams when warranted.

Key Requirements and Technology Experience:

• 5+ years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, or healthcare compliance.
• Active Nursing RN license.
• Core Coding Credentials: At least one active, nationally recognized coding certification from AAPC (CPC, COC, CIC, CPMA) or AHIMA (CCS, CCS-P, RHIT/RHIA).
• Experience in Behavioral Health coding and auditing.
• Knowledge of DSM-5 documentation requirements.
• Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims.

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions.