Delivering healthy outcomes.
Clinical RN Chart Reviewer, CIC or CCS certified
Location
United States
Posted
12 hours ago
Salary
$90K - $110K / year
Seniority
Mid Level
Job Description
Clinical RN Chart Reviewer, CIC or CCS certified
ProgenyHealth, LLC
• 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. • Report to the Payment Assurance Senior 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. • 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. • Ensure 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.
Job Requirements
- Registered Nurse required, preferable NICU
- 2+ years with inpatient claims, required, preferably NICU and maternity
- Inpatient Coding Certification required - CCS or CIC. If not currently certified, requirement to obtain CIC or CCS within 6 months of hire, 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
- 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
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