RN Clinical Auditor - Remote

Job Summary

Working remotely in a full-time capacity, the Clinical Auditor/Analyst will conduct clinical audits and reviews related to fraud, waste, and abuse, analyzing care and services while collaborating with various Health Plan departments.

Key responsibilities:

• Conduct clinical audits and data analysis to identify fraud, waste, and abuse issues
• Utilize fraud detection software to assess and monitor claims and clinical documentation
• Communicate findings and recommendations through written reports and presentations to management and other departments

Required qualifications:

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