The Claims Audit Nurse performs reviews of medical claims data, clinical records and reference materials to ensure proper claims coding, billing and payment. Incumbents report overpayments, underpayments, and other irregularities and confers with Senior Management, Special Investigations Unit, Chief Compliance Officer and General Counsel as needed.
This is a full-time remote opportunity. There is no expectation of being in the office routinely, however, the selected candidate must be a resident of North Carolina and be available to come into the office closest to their residence for team or onsite meetings as needed.
Responsibilities and Duties
Conduct Claims/Medical Record/Coding Audits
Independently audit medical records to interpret and apply in-depth knowledge of clinical and coding principles to identify potential issues.
Substantiate conclusions by using ICD-10 coding expertise, clinical guidelines and industry knowledge.
Review services for medical necessity.
Determine accuracy of principal and secondary diagnosis and procedure codes.
Assist with selection of audit criteria based on historical findings or new coding rules.
Participate in provider appeal process to explain and defend audit findings.
Identify potential fraud and consult with Claims Audit Supervisor and Special Investigations Supervisor on any leads.
Provide data
Identify and provide analytical data based on billing trends/issues and medical cost saving opportunities.
Conduct procedure reviews
Review provider processes against contractual, Federal, State, CMS, and NCQA standards.
Provide support to Investigators/Auditors
Assist with training of Claims Auditors and Investigators on coding principles.
Actively cross train to perform reviews of multiple claim types.
Serve as a coding and clinical resource for the Program Integrity Department and other departments to interpret and explain coding guidelines as needed.
Develop and enhance audit tools
Develop audit tools based on contracted services and requirements defined by CMS, State, Federal, Medicaid and/or NCQA requirements.
Suggest, develop and implement new ideas, approaches and/or technological improvements that will enhance audit production and value.
Minimum Requirements
Graduation from an accredited school of nursing and three (3) years of healthcare experience to include a combination of clinical nursing practice in outpatient and inpatient settings, medical record review and/or claims auditing, or similar experience. Must be licensed in North Carolina as a Registered Nurse.
Knowledge, Skills, and Abilities
Medical record auditing and ICD-10 CM, ICD-10-PCS, APC, ASC, DRG, HCPCS and CPT coding
Knowledge of HIPAA Privacy and Security Rules
Ability to write clear, accurate and concise rationale in support of findings
Ability to manage time, prioritize work, and use problem-solving approaches
Skill in using Microsoft Office products (such as Word, Excel, Outlook, etc.)
Knowledge of the Alliance Health service benefit plans and network providers
Knowledge of legal, waiver, accreditation standards and program practices/requirements
Knowledge of state and federal fraud, waste and abuse statutes and regulations, applicable laws, and regulations including, but not limited to applicable Code of Federal Regulations, NC General Statute and NC Administrative Code.
Skill in communicating, both verbally and in writing
Ability to coordinate effectively with staff from a various agencies as well as other departments
Knowledge of agency and community programs and services which affect Members and Recipients
Knowledge of National Correct Coding Initiative
Certified Professional Coder, Certified Professional Medical Auditor, or similar
Salary Range
$75,600 -$96,390/Annually
Exact compensation will be determined based on the candidate's education, experience, external market data and consideration of internal equity.
An excellent fringe benefit package accompanies the salary, which includes:
Medical, Dental, Vision, Life, Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
