Complex Claims Clinical Reviewer (Remote) at Santa Barbara Cottage Hospital

General Statement of Job

Congratulations! You've landed a remote, home-based position at Vaya Health. This is a Monday-Friday, 8:30am-5:00pm EST role. We're looking for someone with extensive inpatient coding experience and a deep understanding of DRG coding and clinical documentation.

Responsibilities

• Conduct prepayment and post-payment audits of DRG coding and clinical documentation
• Validate the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs
• Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care
• Generate Decision Action Notices that provide clear and concise rationales referencing clinical evidence
• Initiate and verify claim adjustments, maintain audit documentation, and prepare statistical data
• Identify, monitor, and analyze aberrant patterns of utilization or fraudulent activities by healthcare providers through prepayment claims review, post-payment auditing, and provider record review
• Complete prepayment and post-payment claims queries to identify claims that meet high-dollar and complex care criteria

Administrative Activities

• Participate in informal and formal appeal processes, defending decisions before Vaya reconsideration panels, hearing officers, and administrative law judges
• Propose new fraud prevention edits for the automated claims and billing system when new fraudulent schemes are identified

Support Activities

• Perform other duties as assigned, including technical assistance and provider education based upon need, area of expertise, special interests, and availability of resources

Knowledge, Skills, & Abilities

• Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates
• Expert knowledge of DRG & ICD-10 coding required
• Strong working knowledge of applicable industry-based standards
• Proficiency in Word, Access, Excel, and other applications
• Excellent written and verbal communication skills
• Medicaid experience is a plus

Education & Experience Requirements

• Bachelor's degree in nursing with an active license or Bachelor's degree in health information management
• Must have 5 to 7+ years of working with ICD-10 and MS-DRG, with a broad knowledge of medical claims payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology

Licenses & Certifications

• If incumbent qualifies through having a Bachelor’s Degree in Nursing, incumbent must also possess active and unrestricted RN License in the State of North Carolina or Nurse Licensure Compact (NLC) license is required
• Inpatient Coding Credential – CCS preferred

Physical Requirements

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time
• Mental concentration is required in all aspects of work

Residency Requirement

The person in this position must live in NC, SC, GA, TN, VA, MD, or FL for this role.

Pay

Salary depends on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

EEO Statement

Vaya Health is an equal opportunity employer.