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SalaryProgenyHealth empowers our health plan and employer partners to change the trajectory of maternal and infant health outcomes across America. Informed by more than 20 years of experience and patient data, our end-to-end maternal and infant care management solution helps ensure the best possible outcomes for every expecting mother we touch. Our wholly integrated solution builds a network of support for an uninterrupted continuum of care from prenatal health, through any resultant NICU stay, and all the way to one full year of life. From the very beginning, we unite early health risk assessment data with self-directed digital tools and dedicated Case Managers who work tirelessly to connect at-risk moms-to-be with the resources, care, and support they need for a healthy, full-term delivery. By promoting predictable, equitable, and standardized high quality care journeys, we ensure healthier outcomes—and lower costs— across your entire at-risk population. In so doing, we help overcome systemic barriers to support healthier pregnancies and healthier starts to life for all moms and babies, one family at a time.
Job location: This position may be performed remotely – candidates outside of the Eastern PA area will be considered.
Job Role
The Clinical RN Chart Reviewer will perform clinical reviews of inpatient medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. Responsibilities include:
- Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines
- Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered.
- Ensures claims analysis complies with ethical coding standards, guidelines, and regulatory requirements
- Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered
- Research reimbursement regulations for claim payment compliance to support and validate audit findings
- Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures
Qualifications
- Registered Nurse required
- 3 years of experience working in the NICU strongly preferred
- 3+ years of working with ICD-9/10CM, MS-DRG, AP-DRG and APR-DRG with a broad knowledge of medical claims billing/payment systems, provider billing guidelines, payer reimbursement policies, medical necessity criteria and coding terminology required
- Experience in inpatient coding and reimbursement guidelines, and specifically, has a solid understanding of the MS-DRG, AP-DRG and APR-DRG payment systems required
- Inpatient Coding Certification required - CCS or CIC preferred
- Adherence to official coding guidelines, coding clinic determinations, and CMS and other regulatory compliance guidelines and mandates.
- Requires expert coding knowledge - DRG, ICD-10, CPT, HCPCS codes
- Coding certification would be a plus.
- Excellent communication skills, both oral and written
- Strong interpersonal skills that will support collaborative team work
- Proficient in Microsoft Office: Word and Excel; Access – highly preferred
- Ability to work independently and within a team
- Critical listening, thinking, decision making and problem solving
Benefits/Culture
Some of the benefits we offer our team are:
- Paid Time Off
- Paid Parental Leave
- Medical, dental, vision benefits
- 401K with company match
- Short- and Long-Term Disability
- Group Life Insurance
- Tuition reimbursement
- Professional development opportunities
ProgenyHealth positively recruits people from diverse backgrounds, including individuals with disabilities - if you need an accommodation to interview, please contact us by email: careers@progenyhealth.com
