Nursing - Medical Policy Analyst

Job Description:
Job Summary:
This position is responsible for reviewing clinical records to ensure appropriate billing practices utilizing industry standard coding resources. Review requires the use of critical thinking and clinical judgment to make a clinical/coding determination for an individual case. The expectation and outcome from the review process is quality improvement and plan development recommendations. Review will be inclusive of but not limited to DRG and clinical validation reviews. Requires a current working knowledge of ICD-10 coding principles, government correct billing and coding regulation and protocols.

Skills and Abilities:
Demonstrated proficiency in medical record review, chart audits and analysis.
Demonstrated knowledge of diagnosis related group (DRG) assignments and DRG assignment tools.
Demonstrated knowledge of CPT/HCPCS, ICD-10-CM and PCS, coding conventions and rules.
Demonstrated experience with coding and claims processing systems.
Demonstrated ability to apply critical review judgment to make relevant clinical determinations.

Education:
Prefers a Bachelor Degree from an accredited college or university.
Current/Active RN license required.
Highly desirable CIC, COC, CPMA, CPCO

Experience:
Requires a minimum of 3 years of acute care inpatient clinical experience.
Requires 3 years of hospital inpatient coding experience using ICD10 diagnosis and procedure coding within the last 2 years.
Working knowledge of the DRG validation and regulatory requirements.
Working knowledge of Evidence-based care guidelines/MCG a plus.
Experience in claims processing and data management.
Proficient in Excel.
Experience with Adobe Pro
Excellent written and verbal communication skills