North Carolina Licensed Clinical Reviewer

Job Summary

A company is looking for a Complex Claims Clinical Reviewer.

Key Responsibilities

• Conduct prepayment and post-payment audits of inpatient hospital claims, ensuring accuracy of coding and DRG assignment
• Generate Decision Action Notices and maintain audit documentation while analyzing claims for compliance with medical policy
• Participate in appeal processes and collaborate with regulatory bodies to address fraud prevention and compliance issues

Required Qualifications, Training, and Education

• Bachelor's Degree in Nursing or Health Information Management
• 5 to 7 years of experience with ICD-10 and MS-DRG coding
• Broad knowledge of medical claims payment systems and payer reimbursement policies
• Active and unrestricted RN License in North Carolina or Nurse Licensure Compact (NLC) license if qualified through nursing degree
• Inpatient Coding Credential (CCS) preferred