Clinical Nurse Reviewer & Coder

Position Summary

The Clinical Nurse Reviewer \& RN Coder is a highly skilled nursing professional responsible for conducting comprehensive clinical, coding, and reimbursement reviews of medical records, claims, and supporting documentation to ensure accurate representation of healthcare services and claims adjudication for the development of expert witness reports.

This hybrid role combines expertise in clinical nursing, utilization review, medical coding, reimbursement methodologies, and claims adjudication. The Clinical Nurse Reviewer \& RN Coder applies advanced knowledge of medical necessity criteria, coding guidelines, regulatory requirements, and payer policies to evaluate severity of illness, intensity of service, coding accuracy, clinical validation, and reimbursement implications related to an episode of care.

The position collaborates with physicians, nurse reviewers, coding professionals, and legal counsel to support healthcare litigation, appeals, denials management, and reimbursement dispute resolution.

Key Responsibilities

Clinical Review

• Conduct comprehensive clinical reviews of medical records and supporting documentation to determine medical necessity and appropriateness of care.
• Apply utilization review criteria to inpatient and outpatient services, ensuring compliance with payer guidelines.
• Interpret and apply Medicare, Medicaid, CMS regulations, and payer-specific policies and LCDs.
• Evaluate severity of illness and intensity of service utilizing evidence-based criteria.

Coding \& Reimbursement Review

• Perform comprehensive coding reviews to validate the accuracy and completeness of ICD-10-CM, ICD-10-PCS, CPT, and HCPCS code assignment.
• Review and validate DRG and APC assignments and assess reimbursement implications.
• Conduct clinical validation reviews to determine whether documentation supports coded diagnoses and procedures.
• Identify coding discrepancies, documentation deficiencies, and reimbursement opportunities.
• Analyze the impact of coding assignments on claims adjudication and reimbursement outcomes.

Claims Adjudication \& Litigation Support

• Review disputed claims based on clinical documentation, coding guidelines, coverage policies, and other supporting documentation.
• Collaborate with physicians, other nurse reviewers, coding professionals, and legal counsel in the development of expert witness reports and rebuttals.
• Prepare standardized claims review reports in accordance with regulatory and organizational standards.
• Participate in appeals, denials management, payer audits, and reimbursement dispute resolution.

Quality \& Education

• Participate in audits, quality improvement initiatives, and training sessions.
• Maintain current knowledge of coding guidelines, reimbursement methodologies, and regulatory requirements.

Required Experience

• Bachelor's degree in Nursing (BSN preferred).
• Active, unrestricted Registered Nurse (RN) license.
• Minimum of three (3) years of clinical nursing experience.
• Minimum of three (3) years of experience in utilization review, denial management, claims review, or commercial insurance.
• Minimum of three (3) years of inpatient and/or outpatient coding experience.
• Demonstrated experience in claims adjudication, clinical documentation review, and reimbursement methodologies.
• In-depth knowledge of Medicare, Medicaid, CMS regulations, and payer-specific coverage guidelines.
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS, DRG, and APC methodologies.
• Familiarity with InterQual and/or MCG guidelines.
• Strong analytical, communication, and organizational skills.
• Proficiency in Sharepoint, Adobe, and Microsoft Office applications.

Required Certification

• Active, unrestricted Registered Nurse (RN) license.
• One of the following coding certifications is required:
• Certified Professional Coder (CPC)
• Certified Coding Specialist (CCS)
• Certified Inpatient Coder (CIC)
• Certified Professional Medical Auditor (CPMA)

Preferred Skills/Experience

• Certified medical coding experience in acute care/inpatient settings
• RN with dual clinical and coding expertise strongly preferred.
• Experience with DRG validation, clinical validation, payor audits, and reimbursement disputes preferred.
• Experience supporting healthcare litigation is a plus.