Complex Claims Clinical Reviewer (Remote)

Vaya Health

10h•Remote

About The Position

The Complex Claims Clinical Reviewer is responsible for conducting prepayment and post-payment audits of DRG coding and clinical documentation. This role requires an extensive background in inpatient coding and a comprehensive understanding of reimbursement guidelines, particularly DRG payment systems. The position involves auditing inpatient medical records and generating high-quality recoverable claims by evaluating the accuracy of coding and DRG assignment.

Requirements

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.
Bachelor's degree in nursing with an active license or Bachelor's degree in health information management.
5 to 7+ years of working with ICD-10 and MS-DRG.
Broad knowledge of medical claims payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria, and coding terminology.
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.
Inpatient Coding Credential – CCS preferred.

Nice To Haves

Medicaid experience is a plus.

Responsibilities

Conduct 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.
Utilize evidence-based criteria supported by current clinical research to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care.
Generate Decision Action Notices with 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.
Participate in informal and formal appeal processes, defending decisions before Vaya reconsideration panels, hearing officers, and administrative law judges, and providing litigation testimony as applicable.
Work in conjunction with various regulatory bodies to ensure compliance and effectiveness in addressing fraud prevention.
Propose new fraud prevention edits for the automated claims and billing system when new fraudulent schemes are identified.
Perform other duties as assigned, including technical assistance and provider education based upon need, area of expertise, special interests, and availability of resources.