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Responsibilities
Audit and analyze NICU and other inpatient claims using ICD-10 coding principles and clinical guidelines.
Review medical records and billing documentation to validate coding accuracy, medical necessity, and the appropriateness of treatment settings and services.
Assess whether diagnosis and procedure codes and supporting documentation accurately reflect the services delivered.
Research reimbursement regulations and evaluate claims for payment and regulatory compliance.
Identify provider billing discrepancies and recommend adjustments to support appropriate reimbursement.
Use clinical review tools and EMR systems to conduct and document claims reviews.
Help develop audit workflows, policies, procedures, and standard operating documentation.
Qualifications
You must be a Registered Nurse.
You need at least two years of inpatient claims experience, preferably involving NICU and maternity claims.
You must hold a CCS or CIC inpatient coding certification, or obtain one within six months of hire; you are responsible for exam and associated fees.
You need experience in nursing, inpatient coding, and reimbursement guidelines, with a solid understanding of MS-DRG, AP-DRG, and APR-DRG payment systems.
You need at least two years of experience with ICD-9/10-CM, MS-DRG, AP-DRG, and APR-DRG, plus broad knowledge of claims billing and payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
You need expert knowledge of DRG, ICD-10, CPT, and HCPCS codes, and familiarity with official coding guidelines and CMS and other regulatory requirements.
Experience with appeals is strongly preferred.
Microsoft Access proficiency is highly preferred.
Experience using Microsoft Word and Excel will support the stated proficiency requirement.
Work Environment
The position is fully remote.
The listing identifies Plymouth Meeting, Pennsylvania, as the role’s location.
You will report to the Payment Assurance Manager and work independently as well as collaboratively with a team.
The listing describes a business-casual work environment.
The listing does not specify working hours or travel requirements.
Benefits & Perks
Benefits include paid time off and paid parental leave.
Medical, dental, and vision insurance, plus 401(k) with company match, are offered.
Short- and long-term disability coverage and group life insurance are offered.
Tuition reimbursement and professional development opportunities are available.