Clinical RN Chart Reviewer, CIC or CCS certified

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ProgenyHealth, LLC

WebsiteLinkedInAll Job Openings

201 - 500 employees

⚕️ Healthcare Insurance

☁️ SaaS

🧘 Wellness

Healthcare Insurance • SaaS • Wellness

ProgenyHealth, LLC is a company focused on transforming healthcare for women, infants, and families through its integrated Maternity and NICU Care Management solutions. With over 20 years of experience, ProgenyHealth provides a comprehensive care management solution to address the maternity and NICU challenges faced by modern health plans. By identifying risks early, the company aims to prevent preterm births, NICU stays, and complications during pregnancy and after delivery. ProgenyHealth operates as a trusted partner for health plans, overseeing a full maternal and infant care continuum, creating lasting relationships, and optimizing maternal and infant healthcare economics. The company also helps solve non-clinical social drivers impacting maternal and infant health, ensuring equitable, standardized, and predictable family care.

📋 Description

• Perform 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. • Report to the Payment Assurance Senior Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. • 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. • Ensure 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. • Utilize Clinical Review Tools and EMR Systems. • 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. • Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

🎯 Requirements

• Registered Nurse required, preferable NICU • 2+ years with inpatient claims, required, preferably NICU and maternity • Inpatient Coding Certification required - CCS or CIC. If not currently certified, requirement to obtain CIC or CCS within 6 months of hire, applicant responsible for exam and associated fees* • Experience in nursing, inpatient coding and reimbursement guidelines, and specifically, has a solid understanding of the MS-DRG, AP-DRG and APR-DRG payment systems. • 2+ 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. • 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. • Experience with appeals is strongly preferred. • Excellent communication skills, both oral and written. • Strong interpersonal skills that will support collaborative teamwork. • 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

• 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 • Business Casual work environment