Clinical Auditor
4 days ago
Clinical Auditor Job Description
We are seeking a skilled Clinical Auditor to join our team at Medical Mutual. As a Clinical Auditor, you will be responsible for auditing complex outpatient, inpatient, and professional claim irregularities, overpayments, and provider appeals from a clinical coding perspective.
Key Responsibilities:
- Audit outpatient, inpatient, and professional claims from a clinical and coding perspective, applying coding guidelines and edits.
- Assess claims for inappropriate billing combinations, inherent charges, provider supporting documentation, and more.
- Document audit results, including denial reasons and erroneous activities, and update systems accordingly.
- Maintain knowledge of coding and billing guidelines and trends.
- Review provider appeals, applying coding guidelines or edits.
- Identify edits to adjudication systems that are not working properly or need to be installed.
- Interact with internal or external auditors or vendors on claim coding updates and procedure changes.
Requirements:
- Graduate of a registered nursing program approved by the Ohio State Nursing Board. Bachelor's Degree preferred.
- In lieu of RN, Bachelor of Science in medical-related field.
- 3+ years as a Clinical Auditor or equivalent combination of clinical and medical auditing experience.
Preferred Qualifications:
- Certified Medical Auditor (if not certified, required to obtain within 18 months of hire).
- Certified Coder preferred.
Technical Skills and Knowledge:
- Knowledge of ICD codes.
- Knowledge of procedure codes.
- Knowledge of Revenue Codes, HCPC Codes, and CPT codes.
- Knowledge of industry-standard billing rules and regulations for professional claims billing, outpatient claims billing, and inpatient claims billing.
- Knowledge of insurance regulations.
- Knowledge of coding and auditing techniques.
- Good written communication skills.
- Intermediate Microsoft Office and claims adjudications systems skills.
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