Nurse Coder - 256935

Medix™; United States; Remote; USD 70.000 - 95.000; Vollzeit

Zusammenfassung

Medix is seeking an experienced Clinical Nurse Auditor / RN Nurse Coder (Payment Integrity) for a remote, full-time role. You will analyze flagged claims, validate diagnoses, and determine claim validity to protect resources and ensure accurate reimbursement.

Responsibilities include clinical review of inpatient and outpatient claims, identifying upcoding and billing discrepancies, and using our audit platform to document findings and route claims for review.

Qualifikationen

• Active RN license in practice state.
• 2-3+ years clinical nursing experience, inpatient preferred.
• 1-2+ years medical coding or payment integrity experience.
• Experience with ICD-10-CM/PCS, CPT/HCPCS, MS-DRG, and APR-DRG.

Aufgaben

• Review flagged claims for clinical validity and request docs.
• Identify improper coding and upcoding trends.
• Process pre-flagged claim batches with audit indicators.
• Evaluate facility and professional billing, focusing on high-cost inpatient cases.
• Document findings in audit platform and route claims accordingly.

Kenntnisse

RN license

Clinical nursing

Medical coding

Analytical thinking

Clinical decision-making

EHR proficiency

Auditing knowledge

Billing rules

Tools

EHR systems

Audit software

Claims platform

Jobbeschreibung

Job Title: Clinical Nurse Auditor / RN Nurse Coder (Payment Integrity)

Job Type: Full-Time (40 hours/week, Monday - Friday)

Schedule: Standard business hours

Department: Payment Integrity & Claims Audit

Location: Remote

About the Role

We are seeking experienced, detail-oriented Registered Nurses (RNs) with strong clinical acumen and medical coding knowledge to join our growing Payment Integrity team.

In this role, you will analyze flagged claims data, review complex clinical documentation, and identify potential overpayments and billing discrepancies. You will leverage your clinical expertise to validate diagnoses, assess code assignments, and make authoritative determinations on claim validity-protecting healthcare resources while ensuring accurate reimbursement.

Key Responsibilities

• Clinical Review & Determination: Review flagged claims (both inpatient and outpatient) to evaluate the clinical validity of billed services. Make independent clinical determinations, request additional medical documentation when necessary, or escape complex/disputed cases to Medical Directors (MDs) for final review.
• Overpayment & Upcoding Identification: Scrutinize high-dollar claims to identify improper coding and upcoding trends (e.g., distinguishing non-specific myocardial/heart injuries from acute myocardial infarctions/heart attacks).
• Claims Batch Workflow: Work through regular batches of pre-flagged claims containing specific audit indicators and comments required for clinical interpretation and delineation.
• Comprehensive Billing Scope: Evaluate both facility and professional/physician billing, with a heavy emphasis on high-cost inpatient cases.
• System Utilization & Collaboration: Utilize our proprietary audit platform (modeled after industry-standard auditing tools like Cotiviti) to document findings, track audit rationales, and route claims appropriately (comprehensive training provided).

Qualifications

• Licensure: Active, unencumbered Registered Nurse (RN) license in state of practice (Compact license preferred).
• Experience:
• Minimum of 2-3+ years of clinical nursing experience, preferably in an acute care/inpatient hospital setting (ICU, Med/Surg, Cardiology, or ED experience is highly desirable).
• 1-2+ years of experience in medical coding, payment integrity, utilization management, clinical documentation improvement (CDI), or chart audit.
• Certifications (Preferred / Highly Regarded):
• Certified Professional Coder (CPC), Certified Inpatient Coder (CIC), Certified Coding Specialist (CCS), or Certified Clinical Documentation Specialist (CCDS).
• Skills & Knowledge:
• Strong working knowledge of ICD-10-CM/PCS, CPT/HCPCS, MS-DRG, and APR-DRG methodologies.
• Deep understanding of inpatient facility vs. professional billing rules, medical necessity guidelines, and clinical criteria.
• High-level critical thinking skills and comfort with independent clinical decision-making.
• Proficiency with electronic health records (EHR) and payment integrity/claim audit software.