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Clinical Auditor Specialist

1 month ago

Reston, Virginia, United States Medical Mutual Full time
Clinical Auditor Job Description

About the Role

We are seeking a highly 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 other relevant factors.
  • Document audit results, including denial reasons, erroneous activities, and updates to systems.
  • Maintain knowledge of coding and billing guidelines and trends.
  • Review provider appeals, applying coding guidelines and 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, procedure changes, and other relevant matters.

Requirements

  • Graduate of a registered nursing program approved by the Ohio State Nursing Board.
  • Bachelor's Degree preferred.
  • 3+ years of experience as a Clinical Auditor or equivalent combination of clinical and medical auditing experience.
  • Certified Medical Auditor (CMA) certification required within 18 months of hire.
  • Certified Coder (CCS) certification preferred.

Technical Skills and Knowledge

  • Knowledge of ICD codes, procedure codes, 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 and coding and auditing techniques.
  • Good written communication skills and intermediate Microsoft Office and claims adjudications systems skills.