Company

ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns positively impacting maternal and infant health outcomes across America. Our program builds a network of support for an uninterrupted continuum of care from prenatal health, through any resultant NICU stay, and all the way to one full year of life. Our team of neonatologists, pediatricians, and NICU nurses provide continuity of care in collaboration with providers from hospital to caregivers at home and throughout the first year of life. We help overcome systemic barriers to support healthier pregnancies and healthier starts to life for all moms and babies, one family at a time.

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.

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

· 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

Qualifications:

· Registered Nurse required

· Inpatient Coding Certification required - CCS or CIC 

· 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

· 3+ 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

· Excellent communication skills, both oral and written

· Strong interpersonal skills that will support collaborative team work

· 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