Clinical Review and Coding Nurse

Job description

Eviden is an Atos Group business with an annual revenue of circa € 5 billion and a global leader in data-driven, trusted and sustainable digital transformation. As a next generation digital business with worldwide leading positions in digital, cloud, data, advanced computing and security, it brings deep expertise for all industries in more than 47 countries. By uniting unique high-end technologies across the full digital continuum with 55,000 world-class talents, Eviden expands the possibilities of data and technology, now and for generations to come.

 

Shift Schedule: Nightshift 

Work Setup: Hybrid 

 

Summary: 

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The Clinical Review and Coding Nurse is responsible to attain procedure and diagnosis coding accuracy and consistency on referred cases. The RN will perform and coordinate the clinical component of the provider appeal function including communication of the decision on whether to uphold the original payment. The RN will also research new technology or services and recommend updates to medical policies. The RN may also assist in Stop Loss reviews to review member claims and identify potential future high costs.   

Qualifications and Experience:      

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Must have a bachelor's degree in nursing and a Philippine Registered Nurse. 

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Must have a coding certification – CPC (Certified Professional Coder) or CCS (Certified Coding Specialist) 

Duties and Responsibilities:      

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Review cases including review of operative notes to ensure accurate coding is represented based on industry standard coding guidelines. Advise changes that will include all providers for episode of care. Provide recommendation for “Like code” for pricing purposes when code submitted is miscellaneous or does not have standard RVU assigned and when service provided is a covered service. 

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Review cases submitted with coding modifier to determine whether documentation meets modifier standards. If necessary, determine percentage of fee schedule to allow based on clinical records and coding standards.  

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Perform clinical component of provider appeal process. Review appeal documentation, compare to paid claim(s), and evaluate based on policies and procedures. Advise decision in timely manner. Reviews will include appeals of clinical auditing software results. 

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Review medical records to determine medical necessity based on medical policies and industry resources, to uphold appropriateness and quality of health care services.  

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Maintain familiarity with Federal, State and accreditation standards and assist in implementing changes when necessary. 

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Assist in the recommendation and development of policies and procedures related to claim payment, coding, and the hospital review process. 

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Develop knowledge of new reimbursement mechanisms and adapt review systems to accommodate these changes. 

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Participate in medical research of new technology and review of existing policies through multiple resources. Recommend changes to policies based on research and analysis. 

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Actively participate in workgroups and committees as required, e.g., policy committee. 

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Maintain a log for tracking of cases reviewed and report findings and cost savings on a daily basis. 

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Assist in the identification of “high risk” cases and refer them to Case Management. 

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Participate in training classes as outlined by the department, Human Resources, Training department and CDPHP.  

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Suggest, support, and participate in the quality initiatives undertaken by CDPHP Suggest, support and influence programs within the department or company that refine systems and processes and improve overall performance.  

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The employee agrees to comply with CDPHP’s Corporate Compliance Policy and all laws, rules, regulations and standards of conduct relating to the Corporate Compliance Policy and has a duty and obligation to report any suspected violations of any law, the standards of conduct or Corporate Compliance Policy to their immediate Supervisor, the fraud and abuse hotline, the Compliance Officer, the Compliance Director, Human Capital Management or the Chief Executive Officer. 

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Performs other duties as assigned. 

Experience: 

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A minimum of two (2) years clinical experience required, preferably within a hospital setting. 

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A minimum of two (2) years quality/utilization review experience in an HMO, managed care organization, or similar experience as a hospital inpatient coder or auditor required. 

Skills & Abilities:     

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Demonstrated ability to review health care delivery against established criteria. 

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Demonstrated experience working with Microsoft Office, including Outlook, Word and Excel, and other databases.  

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Demonstrated knowledge of ICD-10 diagnosis and procedure codes, CPT codes, Revenue codes, HCPCS codes. 

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Demonstrated ability to pro-actively identify problems and recommend and/or implement effective solutions.  

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Demonstrated ability to work with and maintain confidential information. 

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Demonstrated ability to provide excellent customer service and develop relationships both internally and externally. 

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Excellent verbal and written communication skills. 

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Flexibility to adapt to a changing and fast-paced environment. 

Let’s grow together.