Certified Medical Coder

Job Title: Medical Claim Review Nurse Location: 100% Remote Duration: 3 months (possible extension) Schedule: Monday Through Friday 8am-5pm CANDIDATES MUST LIVE IN ONE OF THE PREFFERED 17 STATES (AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY (outside greater-NYC), OH, SC, TX, UT, WA (outside greater-Seattle), WI) Description: Focused review of professional claims related to Fraud Waste and Abuse, documentation review to support services provided from billing and coding perspective, ensure all state/federal guidelines are utilized, document findings, identify trends, this is a production environment, Top Skills Required: Coding certification with demonstrated experience in Fraud/Waste/Abuse audits, i.e. RAC audits, Special Investigation Units, etc. (able to distinguish approach to audits versus clinical/medical necessity review) . Clinical Validation Reviewer: Performs focused clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, revenue codes, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, acuity alignment, and documentation integrity. Identifies inconsistencies that impact reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate revenue code assignment and determines whether billed services meet coding and billing guidelines, payer policy, and regulatory requirements. Must Have Skills: · Expert in DRG methodologies (e.g., MS & APR) · Expertise in UHDDS definitions, Official Inpatient Coding Guidelines, CMS and Medicaid State Guidelines for billing and coding, and AHA’s Coding Clinic Guidelines. Expertise in evidence-based clinical decision support tools and clinical reference resources such as UpToDate, Client Manual or similar. In-depth knowledge of clinical criteria and documentation requirements to support code assignments. Proven ability to apply critical judgment in clinical and coding determinations. Experience working within applicable state, federal, and third-party regulations. · Analytic, problem-solving, and decision-making skills. Organizational and time-management skills. Attention to detail. Critical-thinking and active listening skills. Effective verbal and written communication skills. Microsoft Office suite and applicable software program(s) proficiency. Required Years of Experience: Requires a minimum of 2 years of experience in inpatient payment integrity medical claim review including DRG Validation or Itemized Bill Review, including 2 years’ experience working with ICD-10, MS-DRG, AP-DRG and APR-DRG, CPT, HCPCS; or any combination of education and experience, which would provide an equivalent background. Required Licensure / Education: · Registered Nurse (RN). License must be active and unrestricted in state of practice. · Preferred: Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient Coder (CIC), Clinical Documentation Improvement Practitioner (CDIP), Certified Professional Coder (CPC), or other advanced HIM/coding certifications.