Clinical RN Chart Reviewer

4 weeks ago

Plymouth Meeting, Pennsylvania, United States ProgenyHealth LLC Full time
Job Description

ProgenyHealth is a leading provider of care management solutions for premature and medically complex newborns, positively impacting maternal and infant health outcomes across America.

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.

Responsibilities include:

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

  • 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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