Job Role

The Clinical RN Chart Reviewer will perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. The Clinical RN Chart Reviewer will report to the Payment Assurance Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. This role requires certified coding expertise and a strong understanding of DRG validation, medical necessity, and regulatory guidelines.

Responsibilities will include:

 · Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines.

· Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered.

· Ensures claims analysis complies with ethical coding standards, guidelines, and regulatory requirements.

· Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered.

· Utilize Clinical Review Tools and EMR Systems.

· Research reimbursement regulations for claim payment compliance to support and validate audit findings.

· Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures.

· Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

Qualifications:

 · Registered Nurse required.

· 2+ years with inpatient claims, preferably NICU and maternity required.

· Inpatient Coding Certification required - CCS or CIC

o If not currently certified, requirement to obtain CIC or CCS within 6 months of hire. 

o Applicant responsible for exam and associated fees. 

· Experience in nursing, inpatient coding and reimbursement guidelines, and specifically, has a solid understanding of the MS-DRG, AP-DRG and APR-DRG payment systems.

· 2+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology.

· Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.

· Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes.

· Experience with appeals is strongly preferred. 

· Excellent communication skills, both oral and written.

· Strong interpersonal skills that will support collaborative teamwork.

· Proficient in Microsoft Office: Word and Excel; Access – highly preferred.

· Ability to work independently and within a team.

· Critical listening, thinking, decision making and problem solving.

Benefits

Some of the benefits we offer our team are:

• Paid Time Off
• Paid Parental Leave
• Medical, dental, vision benefits
• 401K with company match
• Short- and Long-Term Disability
• Group Life Insurance
• Tuition reimbursement
• Professional development opportunities
• Business Casual work environment