Registered Nurse Clinical Reviewer

Job Summary

Providing support for inpatient and outpatient clinical claim review activities, the full-time Remote Registered Nurse Clinical Reviewer will verify coded diagnoses, procedures, and revenue codes to ensure accuracy and compliance with billing guidelines while assessing medical records for clinical integrity.

Key responsibilities

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

Required qualifications

• At least 2 years of experience in inpatient payment integrity medical claim review, including DRG validation
• Active and unrestricted Registered Nurse (RN) license in the state of practice
• Advanced knowledge of DRG methodologies and official coding guidelines
• Expertise in evidence-based clinical decision support tools and clinical reference resources
• Proven ability to apply critical judgment in clinical and coding determinations