North Carolina Licensed Clinical Reviewer
Company: VirtualVocations
Location: Vista
Posted on: May 20, 2025
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Job Description:
A company is looking for a Complex Claims Clinical Reviewer.
Key Responsibilities
Conduct prepayment and post-payment audits of inpatient hospital
claims, ensuring accuracy of coding and DRG assignment
Generate Decision Action Notices and maintain audit documentation
while analyzing claims for compliance with medical policy
Participate in appeal processes and collaborate with regulatory
bodies to address fraud prevention and compliance issues
Required Qualifications, Training, and Education
Bachelor's Degree in Nursing or Health Information Management
5 to 7 years of experience with ICD-10 and MS-DRG coding
Broad knowledge of medical claims payment systems and payer
reimbursement policies
Active and unrestricted RN License in North Carolina or Nurse
Licensure Compact (NLC) license if qualified through nursing
degree
Inpatient Coding Credential (CCS) preferred
Keywords: VirtualVocations, West Covina , North Carolina Licensed Clinical Reviewer, Healthcare , Vista, California
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