[Hiring] Medical Claim Review Nurse @Integrated Resources

Role Description

The Medical Claim Review Nurse will perform focused clinical reviews of inpatient and outpatient claims to ensure accuracy in coding and billing.

• Reviews inpatient and/or outpatient claims to ensure diagnoses, procedures, revenue codes, itemized charges, and Diagnostic Related Groups (DRG) assignments accurately reflect the documented clinical condition and services provided.
• Integrates ICD-10 coding principles, DRG methodologies, revenue code logic, and evidence-based clinical guidelines when reviewing claims for accuracy, appropriateness, and alignment with documentation.
• Performs DRG validation reviews by verifying principal and secondary diagnoses, complications/comorbidities, procedure coding, severity level, and correct grouping logic.
• Conducts itemized bill reviews to confirm that charges are supported by clinical documentation, compliant with billing standards, and appropriate for the level of care delivered.
• Identifies unsupported, inaccurate, or inappropriate coding or billing elements such as unsubstantiated diagnoses, incorrect procedures, or incorrect revenue code usage.
• Develops clear, evidence-based written rationales supporting diagnosis, procedure, revenue code, or DRG recommendations and determinations.
• Substantiates all review outcomes using clinical indicators, documentation, coding guidelines, payer policy, and regulatory requirements.
• Performs review work independently, applying sound clinical judgment and specialized expertise to evaluate complex claim scenarios.
• Applies applicable federal/state regulations, official coding guidelines, payer policies, and Client Payment Integrity standards during all reviews.
• Ensures compliance with DRG and itemized bill review criteria, clinical validation rules, and reimbursement methodologies.
• Collaborates with coding, payment integrity analytics, SIU, and physician advisors to clarify complex clinical documentation, coding discrepancies, or reimbursement determinations.
• Provides subject-matter expertise on DRG validation, revenue code accuracy, itemized bill review, and documentation integrity to internal partners as needed.
• Meets or exceeds established productivity goals set by Payment Integrity leadership for clinical validation and claim review activities.
• Achieves the required accuracy and quality standards for review, diagnosis/procedure validation, and/or itemized bill reviews.
• Participates in quality checks, calibration sessions, and ongoing training to maintain consistency and strengthen review competency.
• Completes special projects and additional review assignments as delegated by leadership.
• Identifies patterns and trends in documentation, coding, or billing that may require internal escalation, provider education, or process improvement.
• Supports continuous improvement efforts by contributing insights that enhance review processes, criteria application, and workflow efficiency.

Qualifications

• Minimum of 2 years of experience in inpatient payment integrity medical claim review including DRG Validation or Itemized Bill Review.
• Experience working with ICD-10, MS-DRG, AP-DRG, APR-DRG, CPT, HCPCS.
• Registered Nurse (RN) with an active and unrestricted license in state of practice.

Requirements

• Expert in DRG methodologies (e.g., MS & APR).
• Expertise in UHDDS definitions, Official Inpatient Coding Guidelines, CMS and Medicaid State Guidelines for billing and coding, and AHA’s Coding Clinic Guidelines.
• Expertise in evidence-based clinical decision support tools and clinical reference resources such as UpToDate, Client Manual or similar.
• In-depth knowledge of clinical criteria and documentation requirements to support code assignments.
• Proven ability to apply critical judgment in clinical and coding determinations.
• Experience working within applicable state, federal, and third-party regulations.
• Analytic, problem-solving, and decision-making skills.
• Organizational and time-management skills.
• Attention to detail.
• Critical-thinking and active listening skills.
• Effective verbal and written communication skills.
• Proficiency in Microsoft Office suite and applicable software program(s).

Benefits

• Pay Rate: $43.39/hr on W2.
• Flexible schedule: 8am to 5pm local time zone.
• Potential for extension past 6 months and/or conversion to an FTE.