North Carolina Licensed Clinical Reviewer

A company is looking for a Complex Claims Clinical Reviewer (Remote). Key Responsibilities Conduct prepayment and post-payment audits of inpatient hospital claims, validating ICD-10-CM and ICD-10 PCS codes Generate Decision Action Notices to provide rationales for claim adjustments, maintaining audit documentation and preparing statistical data Identify and analyze aberrant patterns of utilization or fraudulent activities through claims review and provider record assessments Required Qualifications, Training, and Education Bachelor's degree in nursing or health information management 5 to 7+ years of experience with ICD-10 and MS-DRG coding Active RN license in North Carolina or Nurse Licensure Compact (NLC) license if qualified through nursing degree Inpatient Coding Credential (CCS) preferred Comprehensive knowledge of medical claims payment systems and coding terminology