Registered Nurse Clinical Auditor

Job Summary

Working remotely in a full-time capacity, the Registered Nurse Clinical Auditor will conduct clinical audits and reviews related to fraud, waste, and abuse, while collaborating with various Health Plan departments and utilizing fraud detection software to analyze claims and medical records.

Key responsibilities:

• Respond to fraud, waste, and abuse referrals by completing data analysis and related audits
• Utilize fraud detection software to monitor and assess potential fraud, waste, and abuse
• Review and analyze claims and medical records for appropriateness of coding and clinical care

Required qualifications:

• Registered Nurse (RN) with current licensure
• Five years of clinical experience
• Two years of experience in fraud & abuse auditing, case management, or quality review
• In-depth knowledge of medical terminology, ICD-10, and CPT-4 coding
• Proficiency with Microsoft Office products, including Excel and Access