Remote Pre-Payment Clinical Auditor (RN/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

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.