Medical Claim Review Nurse | Remote | Contract

Medical Claim Review Nurse | Remote | Contract

Walker Healthforce is seeking a Medical Claim Review Nurse with a minimum of 2 years of experience in inpatient payment integrity medical claim review, including DRG Validation and/or Itemized Bill Review. This is a 3-month contract opportunity.

START DATE: 7/6/2026

HOURS/SCHEDULE: Monday - Friday, 8:00 AM - 5:00 PM

WORKER TYPE: Contract (W2 Only)

LOCATION: Remote
Must reside in one of the following approved states:
Arizona, Florida, Georgia, Idaho, Iowa, Kentucky, Michigan, Mississippi, Nebraska, New Mexico, New York (outside Greater NYC), Ohio, South Carolina, Texas, Utah, Washington (outside Greater Seattle), or Wisconsin.

CORE REQUIREMENTS:
• Minimum 2 years of experience in inpatient payment integrity medical claim review
• Experience performing DRG Validation and/or Itemized Bill Reviews
• Minimum 2 years of experience working with ICD-10, MS-DRG, AP-DRG, APR-DRG, CPT, and HCPCS
• Expert knowledge of DRG methodologies, including MS-DRG and APR-DRG
• Active and unrestricted Registered Nurse (RN) license
• Advanced coding certification required (CCS, RHIA, RHIT, CIC, CDIP, CPC, or equivalent)
• Strong understanding of inpatient coding guidelines, reimbursement methodologies, and clinical documentation requirements
• Experience reviewing medical records for coding accuracy, documentation integrity, and reimbursement validation
• Ability to work independently and apply critical clinical judgment in complex review scenarios

ADDITIONAL REQUIREMENTS:
• Expertise in UHDDS definitions, Official Inpatient Coding Guidelines, CMS and Medicaid billing and coding regulations, and AHA Coding Clinic guidance
• Experience utilizing evidence-based clinical reference tools such as UpToDate, Merck Manual, or similar resources
• Strong analytical, problem-solving, and decision-making skills
• Excellent attention to detail and organizational abilities
• Effective verbal and written communication skills
• Experience working within state, federal, and third-party payer regulations
• Proficiency with Microsoft Office Suite and applicable review platforms
• Ability to meet productivity, quality, and accuracy standards in a remote environment
• Strong time management and independent work skills

WE CONSIDER IT A BONUS IF YOU ALSO HAVE:
• Additional experience in Payment Integrity, Clinical Validation, CDI, Audit, or Revenue Integrity functions
• Experience with Medicaid and Medicare claims review
• Prior payer-side review experience
• Advanced expertise in clinical documentation improvement and reimbursement methodologies
• Experience identifying billing trends, coding discrepancies, and process improvement opportunities

JOB RESPONSIBILITIES:
• Review inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and DRG assignments accurately reflect the documented clinical condition and services provided
• Perform DRG validation reviews by evaluating principal diagnoses, secondary diagnoses, complications/comorbidities, procedures, severity levels, and grouping accuracy
• Conduct itemized bill reviews to validate charges, billing compliance, and appropriateness of services rendered
• Apply ICD-10 coding principles, DRG methodologies, revenue code logic, and clinical guidelines during claim reviews
• Identify unsupported diagnoses, incorrect procedures, inaccurate revenue codes, and other coding or billing discrepancies
• Develop clear, evidence-based rationales supporting review determinations and recommendations
• Ensure compliance with payer policies, coding guidelines, reimbursement methodologies, and regulatory requirements
• Utilize clinical indicators and documentation to support review outcomes and reimbursement decisions
• Collaborate with coding teams, Payment Integrity analysts, SIU teams, and physician advisors on complex cases
• Provide subject matter expertise regarding DRG validation, documentation integrity, and claim review best practices
• Meet established productivity, quality, and accuracy standards
• Participate in quality reviews, calibration sessions, and ongoing training activities
• Identify trends in coding, documentation, and billing practices that may require escalation or provider education
• Support continuous improvement initiatives and special projects as assigned

IMPORTANT REMOTE REQUIREMENTS:
• Must reside and work in one of the approved states listed above
• Speed test required prior to submission
• Minimum internet speed requirements:

• Download: 100 Mbps
• Upload: 20 Mbps
  • Internet service must be cable or fiber-based
  • DSL, satellite, and wireless broadband services are not permitted
  • Candidate must maintain updated residence and work location information throughout the engagement
  • Required home office equipment includes dual monitors, docking station, and necessary cables

WHAT WE OFFER:
• Competitive compensation package
• Weekly pay via Direct Deposit
• Medical, Dental & Vision available
• 401(k) options