North Carolina Licensed Clinical Reviewer

Job Summary

A company is looking for a Complex Claims Clinical Reviewer (Remote).

Key Responsibilities

• Conduct prepayment and post-payment audits of inpatient hospital claims, validating ICD-10-CM and ICD-10 PCS codes
• Generate Decision Action Notices to provide rationales for claim adjustments, maintaining audit documentation and preparing statistical data
• Identify and analyze aberrant patterns of utilization or fraudulent activities through claims review and provider record assessments

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
• Active RN license in North Carolina or Nurse Licensure Compact (NLC) license if qualified through nursing degree
• Inpatient Coding Credential (CCS) preferred
• Comprehensive knowledge of medical claims payment systems and coding terminology