Nurse Inpatient Coding Auditor, (Remote) CIC or CCS certified

ProgenyHealth, LLC; Harmonville (PA); On-site; USD 70,000 - 90,000; Full time

Benefits offered by this job

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

Job summary

ProgenyHealth, LLC is seeking a Clinical RN Chart Reviewer to perform clinical reviews of medical records and documentation, validating coding accuracy, medical necessity, and the appropriateness of treatment settings. You will report to the Payment Assurance Manager and support a culture of continuous improvement aligned with our mission.

The role requires certified coding expertise and a strong understanding of DRG validation, medical necessity, and regulatory guidelines.

Qualifications

• RN licensed to practice
• 2+ years inpatient claims experience, preferably NICU and maternity
• CCS or CIC certification; if not, obtain within 6 months of hire
• Solid understanding of MS-DRG, AP-DRG and APR-DRG payment systems
• Experience with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG coding and reimbursement guidelines
• Adherence to official coding guidelines and CMS regulations

Responsibilities

• Audits and analyzes NICU claims according to ICD-10 coding principles and clinical guidelines.
• Analyzes claims data to optimize reimbursement with accurate codes and documentation.
• Ensures compliance with ethical coding standards and regulatory requirements.
• Performs clinical reviews of medical records to validate coding accuracy and medical necessity.
• Utilizes Clinical Review Tools and EMR systems.
• Researches reimbursement regulations to support audit findings.
• Develops claims audit process documentation including SOPs and workflows.
• Detects discrepancies in provider billing and recommends adjustments for proper reimbursement.

Skills

Excellent communication

Interpersonal skills

Independent work

Analytical thinking

Education

Registered Nurse (RN) license

Inpatient coding certification (CCS or CIC)

Tools

Microsoft Word

Microsoft Excel

Microsoft Access

Job description

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.

Description

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.

Requirements

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 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

ProgenyHealth positively recruits people from diverse backgrounds, including individuals with disabilities - if you need an accommodation to interview, please contact us by email: [e-mail]