Clinical RN I - Pre/Post Pay Audit

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

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