Registered Nurse Clinical Reviewer

Job Summary

To ensure accurate coding and billing practices, the full-time Registered Nurse Clinical Reviewer will perform clinical reviews of inpatient and outpatient claims, verifying diagnoses, procedures, and revenue codes while working remotely.

Key responsibilities

• Reviews inpatient and outpatient claims for accuracy in diagnoses, procedures, and revenue codes
• Conducts DRG validation reviews and itemized bill reviews to ensure compliance with clinical documentation and billing standards
• Collaborates with internal teams to clarify documentation discrepancies and provides subject matter expertise on coding and reimbursement issues

Required qualifications

• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Minimum of 2 years of experience in inpatient payment integrity medical claim review, including DRG validation
• Expertise in DRG methodologies and official coding guidelines
• In-depth knowledge of clinical criteria and documentation requirements for coding assignments
• Proven ability to apply critical judgment in clinical and coding determinations