Clinical Validation Reviewer (RN)

Job description

Job Description Job Summary: Performs focused clinical reviews of inpatient and outpatient claims to verify that coded diagnoses, procedures, revenue codes, and corresponding reimbursement methodologies accurately reflect the patient’s documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, acuity alignment, and documentation integrity. Identifies inconsistencies that impact reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate revenue code assignment and determines whether billed services meet coding and billing guidelines, payer policy, and regulatory requirements. Job Duties: - Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and Diagnostic Related Groups (DRG) assignments accurately reflect the documented clinical condition and services provided. - Integrates ICD‑10 coding principles, DRG methodologies, revenue code logic, and evidence‑based clinical guidelines when reviewing claims for accuracy, appropriateness, and alignment with documentation. - Performs DRG validation reviews by verifying principal and secondary diagnoses...