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