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Complex Claims Clinical Reviewer
Vaya HealthComplex Claims Clinical Reviewer handling audits of DRG coding and clinical documentation for Vaya Health. Requires experience in inpatient coding and knowledge of reimbursement guidelines.
Posted 4/30/2026full-timeRemote • Florida, Maryland, North Carolina, South Carolina, Tennessee, Virginia • 🇺🇸 United StatesMid-LevelSenior💰 $68,033 - $88,443 per yearWebsite
About the role
Key responsibilities & impact- Conduct prepayment and post-payment audits of DRG coding and clinical documentation
- Validate the appropriateness of billed ICD-10-CM and ICD-10 PCS codes and MS-DRGs
- Generate Decision Action Notices that provide clear rationales referencing clinical evidence
- Participate in both informal and formal appeal processes, defending decisions
- Propose new fraud prevention edits for the automated claims and billing system
Requirements
What you’ll need- Bachelor's degree in nursing with an active license or Bachelor's degree in health information management
- 5 to 7+ years of working with ICD-10 and MS-DRG
- Expert knowledge of DRG & ICD-10 coding required
- Proficiency in Word, Access, Excel, and other applications
- Medicaid experience is a plus.
Benefits
Comp & perks- Health insurance
- Paid time off
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
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Hard Skills & Tools
ICD-10-CMICD-10 PCSMS-DRGDRG codingclinical documentationfraud prevention editsauditingdecision action notices
Soft Skills
communicationdefending decisionsparticipation in appeal processes
Certifications
active nursing licenseBachelor's degree in nursingBachelor's degree in health information management