Medical Policy Analyst

Schedule:

• 8:00 AM 4:30 PM, rotating weekends

This position is responsible for reviewing clinical records to ensure accurate and compliant billing practices using industry-standard coding resources. The role requires strong critical thinking and clinical judgment to make appropriate clinical and coding determinations on individual cases.

The primary objective of the review process is to support quality improvement initiatives and provide care plan development recommendations. Reviews include, but are not limited to, DRG validation and clinical validation audits. The role requires a current working knowledge of ICD-10 coding principles, as well as government billing and coding regulations and protocols.

• Proficiency in medical record review, chart audits, and clinical analysis

• Strong knowledge of Diagnosis-Related Group (DRG) assignments and DRG assignment tools

• Expertise in CPT/HCPCS, ICD-10-CM, and ICD-10-PCS coding conventions and guidelines

• Experience with coding and claims processing systems

• Ability to apply critical thinking and clinical judgment to make sound clinical determinations

• Bachelors degree from an accredited college or university (preferred)

• Current, active Registered Nurse (RN) license (required)

• Highly desirable certifications: CIC, COC, CPMA, CPCO

• Minimum of 3 years of acute care inpatient clinical experience

• Minimum of 3 years of hospital inpatient coding experience, using ICD-10 diagnosis and procedure coding within the past 2 years

• Working knowledge of DRG validation and regulatory requirements

• Familiarity with evidence-based care guidelines (MCG) preferred

• Experience in claims processing and data management

• Proficiency in Microsoft Excel

• Experience using Adobe Pro

• Excellent written and verbal communication skills