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North Carolina Licensed Clinical Reviewer
A company is looking for a Complex Claims Clinical Reviewer. Key Responsibilities Conduct prepayment and post-payment audits of inpatient hospital claims, ensuring accuracy of coding and DRG assignment Generate Decision Action Notices and maintain audit documentation while analyzing claims for compliance with medical policy Participate in appeal processes and collaborate with regulatory bodies to address fraud prevention and compliance issues Required Qualifications, Training, and Education Bachelor's Degree in Nursing or Health Information Management 5 to 7 years of experience with ICD-10 and MS-DRG coding Broad knowledge of medical claims payment systems and payer reimbursement policies Active and unrestricted RN License in North Carolina or Nurse Licensure Compact (NLC) license if qualified through nursing degree Inpatient Coding Credential (CCS) preferred
A company is looking for a Complex Claims Clinical Reviewer.
Key Responsibilities
Conduct prepayment and post-payment audits of inpatient hospital claims, ensuring accuracy of coding and DRG assignment
Generate Decision Action Notices and maintain audit documentation while analyzing claims for compliance with medical policy
Participate in appeal processes and collaborate with regulatory bodies to address fraud prevention and compliance issues
Required Qualifications, Training, and Education
Bachelor's Degree in Nursing or Health Information Management
5 to 7 years of experience with ICD-10 and MS-DRG coding
Broad knowledge of medical claims payment systems and payer reimbursement policies
Active and unrestricted RN License in North Carolina or Nurse Licensure Compact (NLC) license if qualified through nursing degree
Inpatient Coding Credential (CCS) preferred
