Remote Pre-Payment Clinical Auditor (RN/Coder)

VIVA; United States; Remote; USD 90.000 - 120.000; Vollzeit

Benefits dieser Stelle

Remote work

Zusammenfassung

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.

Qualifikationen

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

Aufgaben

• 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.

Kenntnisse

Clinical auditing

Medical coding

Investigation

Regulatory knowledge

Ausbildung

RN nursing license

Tools

CPC

COC

CIC

CPMA

CCS

CCS-P

RHIT/RHIA

Jobbeschreibung

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.