Registered Nurse Clinical Reviewer

Job Summary

A company is looking for a Clinical Validation Reviewer (RN).

Key Responsibilities

• Conducts clinical reviews of inpatient and outpatient claims to ensure accuracy in coding and billing
• Performs DRG validation reviews and itemized bill reviews to confirm compliance with clinical documentation and billing standards
• Collaborates with internal teams to resolve discrepancies and improve review processes

Required Qualifications

• Active and unrestricted Registered Nurse (RN) license
• Minimum of 2 years of experience in inpatient payment integrity medical claim review
• Expertise in DRG methodologies and official coding guidelines
• In-depth knowledge of clinical criteria and documentation requirements
• Experience working within relevant regulations and coding standards