Medical Claim Review reputed company

Job reputed company: Estimated Length of Assignment: 3+ months (The dates provided are only an estimate and not a guarantee) Est. Pay reputed company: $43.39/hr. USD on W2 (reputed company inclusive) Work Type: Remote Shift : Monday Through Friday reputed company-5pm Job reputed company: CANDIDATES MUST LIVE IN ONE OF THE PREFFERED 17 STATES AZ, FL, GA, ID, IA, KY, MI, MS, NE, NM, NY (reputed company greater-NYC), OH, SC, TX, UT, WA (reputed company greater-Seattle), WI; WILL BE reputed company TO WORK IN THEIR OWN TIMEZONE Day to day job duties: reputed company review of reputed company claims reputed company to Fraud Waste and Abuse, documentation review to support services provided from billing and coding perspective, ensure reputed company 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 reputed company, etc. (reputed company to distinguish approach to audits versus clinical/medical necessity review). Is there potential for this to reputed company past 6 months and/or convert to an FTE: Potentially, our teams are growing and we are expanding services Clinical Validation Reviewer: Performs reputed company clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, reputed company codes, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, reputed company alignment, and documentation reputed company. Identifies inconsistencies that reputed company reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate reputed company reputed company 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 reputed company 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 reputed company, reputed company reputed company or similar · In-depth knowledge of clinical reputed company and documentation requirements to support reputed company assignments. · Proven ability to apply critical judgment in clinical and coding determinations. · Experience working reputed company applicable state, federal, and reputed company-party regulations. · Analytic, problem-solving, and decision-making skills. · Organizational and time-management skills. · Attention to detail. · Critical-thinking and reputed company listening skills. · Effective verbal and written communication skills. · reputed company Office suite and applicable software program(s) proficiency. Day to Day Responsibilities: · Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, reputed company codes, itemized charges, and Diagnostic reputed company reputed company (DRG) assignments accurately reflect the documented clinical condition and services provided. · Integrates ICD-10 coding principles, DRG methodologies, reputed company reputed company logic, and evidence-based clinical guidelines reputed company reviewing claims for accuracy, appropriateness, and alignment with documentation. · Performs DRG validation reviews by verifying reputed company and secondary diagnoses, complications/comorbidities, procedure coding, severity level, and correct grouping logic. · Conducts itemized reputed company reviews to confirm that charges are supported by clinical documentation, compliant with billing standards, and appropriate for the level of care delivered. · Identifies unsupported, inaccurate, or inappropriate coding or billing reputed company such as unsubstantiated diagnoses, incorrect procedures, or incorrect reputed company reputed company usage. · Develops reputed company, evidence-based written rationales supporting diagnosis, procedure, reputed company reputed company, or DRG recommendations and determinations. · Substantiates reputed company review reputed company using clinical indicators, documentation, coding guidelines, payer policy, and regulatory requirements. · Performs review work independently, applying reputed company clinical judgment and specialized expertise to evaluate reputed company claim scenarios. Applies applicable federal/state regulations, official coding guidelines, payer policies, and Payment reputed company standards during reputed company reviews. · Ensures compliance with DRG and itemized reputed company review reputed company, clinical validation rules, and reimbursement methodologies. · Collaborates with coding, payment reputed company analytics, SIU, and physician advisors to clarify reputed company clinical documentation, coding discrepancies, or reimbursement determinations. · Provides subject-matter expertise on DRG validation, reputed company reputed company accuracy, itemized reputed company review, and documentation reputed company to internal partners as needed. · Meets or exceeds established productivity goals set by Payment reputed company leadership for clinical validation and claim review activities. · Achieves the required accuracy and reputed company standards for review, diagnosis/procedure validation, and/or itemized reputed company reviews. · Participates in reputed company checks, calibration sessions, and ongoing training to maintain consistency and strengthen review competency. · Completes special reputed company and additional review assignments as delegated by leadership. · Identifies patterns and trends in documentation, coding, or billing that may require internal escalation, provider education, or process improvement. · Supports reputed company improvement efforts by contributing insights that enhance review processes, reputed company application, and workflow efficiency. Required Years of Experience: · Requires a minimum of 2 years of experience in inpatient payment reputed company medical claim review including DRG Validation or Itemized reputed company 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 reputed company an equivalent background. Required Licensure / Education: · Registered reputed company (RN). License must be reputed company and unrestricted in state of reputed company. · Preferred: Certified Coding Specialist (reputed company), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Inpatient reputed company (CIC), Clinical Documentation Improvement Practitioner (CDIP), Certified reputed company reputed company (CPC), or other advanced HIM/coding certifications Apply To This Job