Clinical Auditor

Medical Mutual•Cleveland, OH

3d•Remote

About The Position

Medical Mutual is hiring a remote Clinical Auditor. Applicants must reside within 50 miles of the company’s Brooklyn, Ohio office. The role works under general supervision and audits complex outpatient, inpatient, and professional claims, irregularities, overpayments, and provider appeals from a clinical coding perspective, applying coding guidelines. It analyzes provider billing for abnormalities, questionable practices, and proper coding combinations, and documents denial reasoning or erroneous activity. The posting also describes a Senior Clinical Auditor level with broader recovery and spending-control research, implementation, and staff-training responsibilities. The Clinical Auditor maintains knowledge of coding and billing guidelines and trends; reviews appeals; identifies adjudication-system edits that are malfunctioning or need installation; and works with senior colleagues to implement changes. The role interacts with auditors and vendors, discusses consult findings with Physician Reviewers, and reviews edit updates and questions with payment recovery staff. A Certified Medical Auditor credential is required within 24 months of hire if not already held; certified coding credentials are preferred for the Clinical Auditor level. Medical Mutual provides equipment for the role, including a laptop, monitors, keyboard, mouse, and headset. The company describes benefits and employee programs including a bonus program, retirement contributions, insurance coverage, PTO and holidays, eligible parental leave, career development, mentoring, and tuition reimbursement.

Requirements

Graduate of a registered nursing program approved by the Ohio State Nursing Board, or a Bachelor of Science in a medical-related field in lieu of RN.
Three years as a Clinical Auditor or an equivalent combination of clinical and medical auditing experience for the Clinical Auditor level.
Five years as a Clinical Auditor or an equivalent combination of clinical and medical auditing experience for the Senior Clinical Auditor level.
Certified Medical Auditor certification; if not certified, must obtain it within 24 months of hire for the Clinical Auditor level.
For the Senior Clinical Auditor level, Certified Coder or Certified Medical Auditor certification; if not certified, must obtain it within 24 months of hire.
Knowledge of ICD codes, procedure codes, Revenue Codes, HCPC Codes, and CPT codes.
Knowledge of industry-standard billing rules and regulations for professional, outpatient, and inpatient claims.
Knowledge of insurance regulations and coding and auditing techniques.
Good written communication skills for the Clinical Auditor level; strong written communication skills for the Senior Clinical Auditor level.
Intermediate Microsoft Office and claims adjudication systems skills for the Clinical Auditor level; intermediate to advanced skills for the Senior Clinical Auditor level.
Applicants must reside within 50 miles of the Brooklyn, Ohio office.

Nice To Haves

Bachelor’s degree preferred.
Certified Coder preferred for the Clinical Auditor level.
Certified Medical Coder credential such as CPC, CCS, or equivalent preferred.

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 related issues.
Document audit results, including denial reasons and erroneous activity, and update systems accordingly.
Maintain knowledge of coding and billing guidelines and trends.
Review provider appeals using coding guidelines or edits.
Identify adjudication-system edits that are not working properly or need to be installed so claims can be processed, and work with senior colleagues to implement changes.
Interact with internal or external auditors and vendors regarding claim coding updates and procedure changes.
Discuss consult findings with Physician Reviewers and review edit updates and questions with payment recovery staff.
For the Senior Clinical Auditor level, identify recovery and avoidance opportunities, research ways to control medical spending, and present ideas to management.
For the Senior Clinical Auditor level, participate in implementing new or updated policies and processes and orient, train, assist, and review the work of more junior staff.
Perform other duties as assigned.

Benefits

Employee bonus program.
401(k) with company match up to 4% and an additional company contribution.
Health Savings Account with a company matching contribution.
Medical, dental, vision, life, and disability insurance.
Employee Assistance Program with counseling, coaching, self-help resources, and work/life benefits assistance.
Company holidays and up to 16 PTO days during the first year, with options to carry over unused PTO.
Parental leave after 120 days of service for eligible employees who become parents through maternity, paternity, or adoption.
Career development programs and classes.
Mentoring and coaching.
Tuition reimbursement up to $5,250 per year.
Access to on-site fitness centers or gym membership reimbursement where a Medical Mutual facility is unavailable.
On-site cafeteria at the Brooklyn, Ohio headquarters.
Employee discounts at local businesses.
Cash rewards for shopping with company customers.
Business Resource Groups and a diverse, inclusive, and welcoming culture.
Equipment provided for the role, including a laptop, monitors, keyboard, mouse, and headset.