Sr. Clin Claim Review RN
The Judge Group
Remote
USD 55-55 / hour
Clinical Coding Auditor – RN
Location: Remote
Schedule: Standard business hours (Monday–Friday)
Pay Rate: $55/hour
Contract-to-Hire: High performers eligible for conversion after 3 months
Start date is ASAP
Contract goes through 4/24/26 and possible to go perm (4-6 months then maybe go perm depending on approvals
Training will be normal business hours – CST or EST hours
Primary Responsibilities:
• Conduct MS-DRG and APR-DRG coding reviews to verify the accuracy of DRG assignment and reimbursement with a focus on overpayment identification
• Expert knowledge of and the ability to: identify the ICD-10-CM/PCS code assignment, appropriate code sequencing, present on admission (POA) assignment, and discharge disposition, in accordance with CMS requirements, ICD-10 Official Guidelines for Coding and Reporting, and AHA Coding Clinic guidance
• Must be fluent in the application of current ICD-10 Official Coding Guidelines and AHA Coding Clinic citations, in addition to demonstrating working knowledge of clinical criteria documentation requirements used to successfully substantiate code assignments
• Perform clinical coding review to ensure accuracy of medical coding and utilizes clinical expertise and judgment to determine correct coding and billing
• Solid command of anatomy and physiology, diagnostic procedures, and surgical operations developed from specialized training and extensive experience with ICD-10-PCS code assignment
• Writes clear, accurate and concise rationales in support of findings using ICD-10 CM/PCS Official Coding Guidelines, and AHA Coding Clinics
• Utilize proprietary workflow systems and encoder tool efficiently and accurately to make audit determinations, generate audit rationales and move claims through workflow process correctly
• Demonstrate knowledge of and compliance with changes and updates to coding guidelines, reimbursement trends, and client processes and requirements
• Maintain and manages daily case review assignments, with a high emphasis on quality
• Provide clinical support and expertise to the other investigative and analytical areas
• Will be working in a high-volume production environment that is matrix driven
Day in the life
Auditors: coding and clinical review – 15 claims per day
- Must enter auditing notes into system as well
- Review any feedback that comes from sally (they send feedback often)
- They can always reach out with questions
- Main role is to review claims and complete queue on daily basis
- They try to keep distractions on auditors at a minimum
- They won’t be expected to do 15 claims right away
- They will gradually increase to 15 claims per day
Soft Skills:
• Ability to use a Windows PC with the ability to utilize multiple applications at the same time
• Demonstrate excellent written and verbal communication skills, strong analytical skills, and attention to detail
• Ability to work independently in a remote environment and deliver exceptional results
• Excellent time management and work prioritization skills
Required Qualifications:
• Unrestricted RN (registered nurse)
• CCS/CIC
• 3+ years of MS DRG/APR DRG coding experience in a hospital environment with expert knowledge of ICD-10 Official Coding Guidelines and DRG reimbursement methodologies
• Expert knowledge of ICD-10-CM coding including but not limited to: expert knowledge of principal diagnosis selection, complications/comorbidities (CCs) and major complications/comorbidities (MCCs), and conditions that impact severity of illness (SOI) and risk of mortality (ROM)
• Expert knowledge of ICD-10-PCS coding including but not limited to: expert knowledge of the structural components of PCS including but not limited to: selection of appropriate body systems, root operations, body parts, approaches, devices, and qualifiers