Role: Clinical RN I – Pre/Post Pay Audit
Location: Remote (NJ, NY, PA, CT, DE)
Job Summary
Performs pre- and post-pay clinical audits to ensure documentation accuracy, authorization validation, and compliance with medical necessity criteria. Follows defined guidelines and escalates as needed.
Key Responsibilities
- Conduct pre/post-pay audits using standard guidelines
- Review claims, clinical documentation, and authorizations
- Compare cases against MCG criteria
- Document findings and update audit trackers
- Identify gaps and escalate issues as required
- Ensure compliance with audit standards and policies
Tools & Systems
- Excel, ECM/DMS (ITS), Care Radius, MCG
- Outlook / Teams
Requirements
- Active RN license (unrestricted)
- ASN or BSN
- Experience in utilization review, clinical audits, or documentation review
- Strong attention to detail and documentation accuracy
Preferred
- Pre/post-pay audit experience
- Familiarity with MCG criteria and audit systems
- Experience with regulatory/state audits