Program Integrity Clinical Reviewer II

CareSource

. Evaluate medical records for correct documentation, trends, patterns, missing information, upcoding, unbundling, and compliance with clinical documentation, medical standards, and CPT, HCPCS, and ICD-10 codes .

Posted 10/5/2026full-timeRemote • United StatesMid-LevelSenior💰 $72,200 - $115,500 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in auditing medical records and claims, with a strong foundation in CPT, HCPCS, and ICD-10 coding. Proficient in developing training materials and conducting investigations while maintaining compliance with medical standards and regulations.

Highest-signal resume keywords

CPT Coding KnowledgeICD-10 Coding KnowledgeFraud, Waste, Abuse Investigation ExperienceCurrent RN LicensureCertified Medical Coder (CPC, RHIT, RHIA)

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Record AuditingClaims ReviewAnalytical SkillsProject ManagementNegotiation SkillsProblem SolvingTraining DevelopmentClinical Documentation ComplianceAttention to DetailInvestigative Skills

Soft Skills

Excellent Communication SkillsTeam CollaborationIndependent Work Ability

Tools & Technologies

Microsoft Office WordMicrosoft Office ExcelMicrosoft Office PowerPoint

Certifications & Qualifications

Current RN LicensureCertified Medical Coder (CPC, RHIT, RHIA)

Industry Keywords

MedicareMedicaidManaged CareClinical StandardsDocumentation TrendsCorrective Action PlansUtilization ManagementAdult Learning Environment

About the role

Key responsibilities & impact

Evaluate medical records for correct documentation, trends, patterns, missing information, upcoding, unbundling, and compliance with clinical documentation, medical standards, and CPT, HCPCS, and ICD-10 codes
Conduct claim reviews against medical records to determine claim accuracy for payment, supporting prepayment, post-payment, and SIU teams
Present identified clinical issues and research to Medical Directors and physician experts for validation
Conduct, participate in, or contribute to on-site audits and investigations of medical professionals, subcontractors, and contracted entities
Assist audit and investigative teams in developing clinical and coding-based audit tools
Draft proposed provider education and formal corrective action plans for clinical and coding deficiencies
Provide SIU perspective to clinical and payment policies and the Utilization Management Committee
Collaborate with Pharmacy, Medical Management, Provider Relations, Claims, Contracting, Case Management, Legal, and other departments
Maintain confidentiality of sensitive investigative information
Develop and maintain SIU-specific clinical and investigative training materials and SOPs
Create and execute monthly audits of investigative staff work to ensure processes are followed and identify training opportunities
Create, use, and provide training mediums including presentations, quick reference tools, speakers, internet, and state and federal resources
Perform other job-related instructions as requested

Requirements

What you’ll need

Bachelor of Science degree or equivalent experience years of relevant experience is required
Minimum of five (5) years clinical practice experience required
Significant experience auditing medical records against claims required
Prior Fraud, Waste, Abuse (FWA) investigation and auditing experience preferred
Medical research experience preferred
CPT, HCPCS and ICD-10 coding knowledge required
Knowledge of Medicare/Medicaid/Managed Care preferred
Proficient with Microsoft Office Word, Excel and PowerPoint
Broad-based clinical and medical coding knowledge
Strong analytical skills with high attention to details
Skill in negotiating issues and resolving problems
High-level investigative experience
Training/teaching experience and demonstrated knowledge of adult learning environment
Excellent written and verbal communication skills with adeptness to create, present and evaluate department and role-focused teaching materials
Ability to communicate verbally and in written form with a variety of levels within the organization
Critical decision making/problem solving skills
Considerable skill set in planning and project management
Ability to work independently and within a team environment
Current, unrestricted RN licensure in state of practice required
Certified Medical Coder (CPC, RHIT or RHIA) required at time of hire or within 18 months of hire date

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Comprehensive total rewards package
Equal Opportunity Employer environment focused on belonging and support for individuals of all backgrounds