RN Clinical Documentation Specialist

Company: CareNational Healthcare Services
Location: Orange
Posted on: February 23, 2021

Job Description:

Clinical Documentation Specialist RN (Registered Nurse)--- Managed Care
Orange, CA
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*** This is a Full Time, Benefits Available, CONTRACT opportunity, expected to last 4-6--months or longer! ***

The Clinical Documentation Specialist RN (Registered Nurse) provides clinical code expertise regarding claims editing, reimbursement rules, clinical coding, clinical rationale, and decision making of hospital and professional claims. This position will be responsible for overseeing the vendor's submission(s) to ensure coding and claims guidelines are followed according to the regulatory standards.

• Conducts coding audits of submitted claims, which includes but not limited to review of professional, in-patient, and out-patient claims data and/or medical records to determine appropriateness of procedures and diagnosis codes billed.
• Creates a standardized audit tool for review of hospital, outpatient, and professional claims to ensure consistency and appropriateness of audit reviews.
• Develops audit reports of audit findings at both the detail and summary level with month to date and year to date metrics, and recommendations for program improvements.
• Gathers and analyzes information and summarizes findings and metrics pertinent to documentation of chart review investigations; shares information with impacted departments.
• Assesses medical records as applicable to ensure they substantiate services billed; shares anomalies identified with code review team and recommends areas for follow-up.
• Evaluates claims billed for the appropriate Current Procedural Terminology (CPT), ICD-10, Healthcare Common Procedure Coding System (HCPCS) codes, and modifiers as applicable.
• Ensures issues related to compliance reimbursement bundling/unbundling plus fragmentation of coding information are monitored and assists management in medical claims processing studies to define claims editing trends.
• Reviews high dollar professional and facility claims to validate charges paid to ensure documentation supports level of care billed.
• Analyzes health claim history reports to identify coding as well as billing patterns and determines the appropriateness of the ICD-10-CM/PCS, CPT, HCPCS, or revenue codes billed.

Keywords: CareNational Healthcare Services, Orange , RN Clinical Documentation Specialist, Healthcare , Orange, California