Auditor Clinical Validation Outpatient Specialty Clinical in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Auditor Clinical Validation Outpatient Specialty Clinical based in the United States.

This role sits at the intersection of clinical expertise and advanced medical coding audit work, focusing on the validation of outpatient and specialty claims. You will evaluate medical records with a strong emphasis on coding accuracy, clinical appropriateness, and regulatory compliance across diverse care settings. The position requires deep analytical judgment to assess medical necessity and identify billing inconsistencies in complex claims. Working independently, you will apply established coding frameworks and audit methodologies to ensure precision and integrity in claims review. You will also contribute to improving audit processes by identifying trends, risks, and opportunities for enhanced efficiency. This is a highly detail-oriented role within a structured, compliance-driven environment where accuracy directly impacts healthcare reimbursement integrity.

• Perform detailed outpatient and specialty claims audits by reviewing medical records and applying clinical coding principles to validate billing accuracy, medical necessity, and treatment appropriateness across multiple care settings such as outpatient services, diagnostics, pharmacy, and inpatient-related claims.
• Use advanced audit systems and coding tools to document findings, ensure accurate claim entry, and support consistent application of client-specific guidelines and regulatory standards.
• Maintain defined productivity, quality, and accuracy benchmarks while independently managing assigned audit workloads and ensuring timely completion of reviews.
• Identify complex coding discrepancies, evaluate claims outside standard audit scope, and contribute insights for potential recovery opportunities or expanded audit concepts.
• Collaborate on process improvement by recommending enhancements to audit methodologies, tools, and workflows based on findings and emerging claim patterns.

• Associate or Bachelor’s degree in Nursing with an active and unrestricted clinical license, combined with strong experience in medical coding or auditing within healthcare claims environments.
• Active coding certification (such as CPC, CIC, CCS, CCS-P, RHIA, or RHIT) with strong command of ICD-10, CPT, HCPCS coding systems and official coding guidelines.
• 5–7 years of experience in clinical medical record coding, auditing, or utilization review with strong understanding of HIPAA regulations, CMS requirements, and payer reimbursement policies.
• Strong analytical skills with the ability to interpret complex medical records, evaluate clinical documentation, and draw accurate, evidence-based conclusions.
• Excellent written and verbal communication skills with the ability to work independently in a remote, detail-heavy, compliance-focused environment.
• Strong attention to detail, organizational discipline, and ability to manage sustained periods of focused analytical work in a structured workflow.

• Competitive compensation structure with an hourly rate equivalent to approximately $95,000 annually, plus potential discretionary bonus eligibility
• Comprehensive healthcare coverage including medical, dental, and vision insurance
• Retirement savings plan with 401(k) options
• Paid time off package ranging from 17 to 27 days depending on tenure and level, plus 9 paid holidays
• Life insurance, disability coverage, and family leave benefits
• Remote work arrangement with required home office setup and internet reimbursement expectations