Clinical RN Chart Reviewer, CIC or CCS certified

ProgenyHealth, LLC

Clinical RN Chart Reviewer performing clinical reviews of medical records for claims coding accuracy. Role involves auditing NICU claims and ensuring compliance with coding standards and guidelines.

Posted 7/10/2026full-timeRemote • 🇺🇸 United StatesJuniorMid-Level💰 $90,000 - $110,000 per yearWebsite

About the role

Key responsibilities & impact

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

What you’ll need

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

Comp & perks

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

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Clinical ReviewClaims Coding AccuracyMedical Necessity ValidationReimbursement OptimizationCoding Guidelines AdherenceDRG KnowledgeCPT CodesHCPCS CodesICD-9/10CM ExperienceClaims Billing Systems

Soft Skills

Excellent Communication SkillsStrong Interpersonal SkillsCritical ThinkingDecision MakingProblem Solving

Certifications

Registered NurseInpatient Coding Certification - CCS or CIC