Medical Review Nurse - Clinical Validation

Key Responsibilities

• Auditing claims for medically appropriate services provided for inpatient settings while applying appropriate medical review guidelines, policies and rules.
• Document all findings referencing the appropriate policies and rules.
• Generate letters articulating audit findings.
• Support your findings during the appeals process if requested.
• Work collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse.
• Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients.
• Work with the team to minimize the number of appeals; suggest ideas that may improve audit workflows; assist with QA functions and training team members.
• Cross train in all clinical departments/areas.
• Other duties as required to meet business needs.

Knowledge, Skills And Abilities Needed

• Experience with utilization management systems or clinical decision-making tools such as Medical Coverage Guidelines (MCG) or InterQual.
• Experience with and deep knowledge of ICD-9, ICD-10, CPT-4 or HCPCS coding.
• Knowledge of insurance programs program, particularly the coverage and payment rules.
• Ability to maintain high quality work while meeting strict deadlines.
• Excellent written and verbal communication skills.
• Ability to manage multiple tasks including desk audits and claims review.
• Must be able to independently use standard office computer technology (e.g. email, SharePoint, slack, outlook calendar etc.).
• Must be able to manage multiple assignments effectively, create documentation outlining findings and/or documenting suggestions, organize and prioritize workload.
• Effectively work independently and as a team, in a remote setting.

Education Requirements

• An associate or bachelor’s degree in nursing (active/unrestricted RN license).

Required And Preferred Qualifications

• Inpatient claims auditing, quality assurance or recovery auditing experience of 2 years or more required, and/or Inpatient Clinical Documentation Integrity experience of 2 years or more required.
• Strong focus on quality and attention to detail.
• Deep curiosity and analytical skills to understand root causes of events and behaviors.
• Proven ability to apply critical judgment in clinical and coding determinations.
• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
• Expert in DRG methodologies (e.g., MS & APR).
• Expertise in ICD-10-CM/PCS coding, UHDDS definitions, Official Coding Guidelines, and AHA’s Coding Clinic Guidelines.
• Ability to work independently and efficiently with minimal supervision.