Director II, Clinical Documentation
Ensemble Health Partners
Unity
Nurse Claims Analyst
ZipLiens
full-time
Posted on:
Origin: • 🇺🇸 United States • North Carolina
Visit company websiteSalary
💰 $75,000 - $90,000 per year
Job Level
Mid-LevelSenior
About the role
- Conduct high-volume QA reviews of claimant-level medical records (up to 1,000 per week), using clinical judgment and knowledge of medical coding to determine relatedness to the underlying litigation.
- Help create and establish medical claim audit protocols to enable consistent and defensible determinations.
- Use Excel/Google Sheets to efficiently manage and analyze large datasets, creating workflows that streamline reviews and reduce the need for one-off line-by-line analysis.
- Document review findings and rationales clearly and accurately for use by internal teams and clients.
- Identify trends or recurring issues in claim reviews and recommend updates to processes or protocols to improve consistency and accuracy.
- Support knowledge sharing by documenting review standards and providing clinical guidance to internal team members and vendors.
- Adapt review approach across multiple claim types to meet evolving client and project needs.
- Ensure reviews and determinations meet accuracy, quality, and productivity standards that support reliable client outcomes.
- Contribute subject matter expertise to reports, analysis, and special projects that strengthen review protocols and client deliverables.
Requirements
- 3+ years of experience in medical record review, claims auditing, or medical billing and coding.
- 1+ years of experience in itemized bill review (or equivalent claims review experience).
- Active, unrestricted RN license in good standing within the United States is required.
- Strong understanding of payer policies and medical coding systems such as CPT, ICD-9/10, and HCPCS.
- Proficiency in Excel (e.g., formulas, pivot tables, data analysis) to manage and evaluate large claim datasets.
- Excellent written communication skills, including ability to write clear, concise, fact-based rationales.
- Ability to evaluate medical information and apply clinical judgment to make defensible determinations on claim appropriateness.
