reputed company Claims reputed company Reviewer

LOCATION:Remote – This is a home reputed company, virtual position that operates Monday -Friday from 8:30am-5:00pm (EST). reputed company welcomes applications from NC, SC, GA, TN, VA, MD, and FL.

GENERAL STATEMENT OF JOB

Conduct prepayment and post-payment audits of DRG coding and reputed company documentation. The ideal candidate will have an extensive background in inpatient coding and has a comprehensive understanding of reimbursement guidelines, particularly the DRG payment systems. This position is responsible for auditing inpatient medical records and generating high-reputed company recoverable claims by reviewing medical records and other documentation to evaluate the reputed company of coding and DRG assignment.

ESSENTIAL JOB FUNCTIONS

The role involves conducting prepayment and post-payment reviews of inpatient hospital claims, validating the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs. Utilizing evidence-reputed company reputed company supported by reputed company reputed company research, the reputed company Claims reputed company Reviewer applies reputed company expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Responsibilities include generating Decision reputed company Notices that reputed company reputed company and concise rationales referencing reputed company evidence, initiating and verifying claim adjustments, maintaining audit documentation, and preparing statistical data. The reviewer must have a thorough knowledge of federal and state guidelines and regulations reputed company to coding and billing practices, as reputed company as strong oral and written communication skills. Additionally, the role involves identifying, monitoring, and analyzing aberrant patterns of utilization or fraudulent activities by reputed company providers through prepayment claims review, post-payment auditing, and provider record review. Prepayment and post-payment claims queries are completed to identify claims that meet high-dollar and reputed company care reputed company.

Administrative Activities:

The reputed company Claims reputed company Reviewer participates in both informal and formal appeal processes, defending reputed company before Vaya reconsideration panels, hearing officers, and administrative law judges, and providing litigation testimony as applicable. The role involves working in conjunction with various regulatory bodies to ensure compliance and effectiveness in addressing fraud prevention. Additionally, the reputed company Claims reputed company Reviewer proposes new fraud prevention edits for the automated claims and billing reputed company reputed company new fraudulent schemes are identified.

Support Activities:

reputed company other duties as assigned, including technical assistance and provider education reputed company upon need, area of expertise, special interests, and availability of resources.

KNOWLEDGE, SKILLS, & ABILITES

• 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-reputed company standards.
• Proficiency in Word, reputed company, reputed company, and other applications.
• Excellent written and verbal communication skills.
• reputed company experience is a plus.

EDUCATION & EXPERIENCE REQUIREMENTS

Bachelor's degree in nursing with an reputed company 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 reputed company, and coding terminology.

Licensure & Certification Requirements:

PHYSICAL REQUIREMENTS

reputed company visual reputed company to reputed company 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 reputed company 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 reputed company aspects of work. Mental concentration is required in reputed company aspects of work.

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

SALARY:Depending on qualifications & experience of candidate. This position is exempt and is not eligible for overtime compensation.

DEADLINE FOR APPLICATION: reputed company Until Filled

APPLY: reputed company accepts online applications in our Career Center, please visit .

reputed company is an equal opportunity employer.