Clinical RN Chart Reviewer, CIC or CCS certified

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct clinical evaluations of medical records and other documentation to confirm the accuracy of claims coding, medical necessity, and the suitability of treatment settings and services provided.

• Report to the Payment Assurance Senior Manager and foster a culture and workplace that encourages and inspires a continuous improvement mindset regarding products and services in alignment with our company mission.

• Perform audits and analyses of neonatal intensive care unit (NICU) claims in accordance with ICD-10 coding standards and clinical guidelines.

• Analyze claims data to maximize reimbursement by ensuring that diagnosis codes, procedure codes, and supporting documentation accurately reflect the services rendered.

• Ensure compliance of claims analysis with ethical coding standards, guidelines, and regulatory requirements.

• Responsible for conducting clinical assessments of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services provided.

• Utilize Clinical Review Tools and EMR Systems effectively.

• Research reimbursement regulations for claim payment compliance to substantiate and validate audit findings.

• Assist in the creation of documentation for claims audit processes, including workflow diagrams, policies and procedures, and standard operating procedures.

• Identify discrepancies in provider billing and suggest modifications to ensure accurate reimbursement.

⛳️ Requirements

• Must be a Registered Nurse, preferably with NICU experience.

• Minimum of 2 years of experience with inpatient claims is required, ideally in NICU and maternity.

• Inpatient Coding Certification is required - CCS or CIC. If not currently certified, the candidate must obtain CIC or CCS within 6 months of hire, with the applicant responsible for the exam and associated fees.

• Experience in nursing, inpatient coding, and reimbursement guidelines, with a strong understanding of MS-DRG, AP-DRG, and APR-DRG payment systems.

• At least 2 years of experience working with ICD-9/10CM, MS-DRG, AP-DRG, and APR-DRG, along with comprehensive knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.

• Compliance with official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates is essential.

• Requires expert knowledge in coding - DRG, ICD-10, CPT, and HCPCS codes.

• Experience with appeals is highly preferred.

• Exceptional communication skills, both verbal and written.

• Strong interpersonal skills that facilitate collaborative teamwork.

• Proficient in Microsoft Office applications: Word and Excel; Access is highly preferred.

• Ability to work autonomously as well as part of a team.

• Strong critical listening, thinking, decision-making, and problem-solving abilities.

🏝️ Benefits

• Paid Time Off

• Paid Parental Leave

• Medical, dental, and vision benefits

• 401K with company match

• Short- and Long-Term Disability

• Group Life Insurance

• Tuition reimbursement

• Opportunities for professional development

• Business Casual work environment