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, analyzing care services, coding requirements, and resource utilization while collaborating with various Health Plan departments.

Key responsibilities:

• Respond to fraud, waste, and abuse referrals, completing data analysis and related audits as assigned
• Utilize fraud detection software to monitor potential fraud, waste, and abuse in claims and medical records
• Write concise reports with statistical data to communicate findings and recommendations to management and other departments

Required qualifications:

• Registered Nurse (RN) with current licensure
• Five years of clinical experience and two years of experience in fraud & abuse, auditing, or quality review
• In-depth knowledge of medical terminology, ICD-10, and CPT-4 coding
• Proficiency in Microsoft Office products, including Excel and Access
• Preferred certifications include AAPC or AHIMA designations (CPC, CPMA, CIC, CCA, CCS, CCS-P)