CLINICAL REVIEWER II - CODER

JOB TITLE: CLINICAL (CODING) REVIEWER

COMPANY OVERVIEW

Cloudmed is a first-of-its-kind, single-source enterprise platform provider of Revenue Intelligence™ solutions for hospitals. Cloudmed’s approach of combining human expertise with advanced technology utilizing machine learning algorithms provides a smarter, more predictive way for clients to realize all potential revenue. Today, Cloudmed partners with over 3,100 healthcare providers in the United States and recovers over $1.2 billion of underpaid or unidentified revenue for clients annually. Cloudmed (Triage solution) is the 2020 Revenue Integrity and Underpayment Services KLAS® Category Leader and its solution suites have HFMA Peer Review status and are HITRUST certified.

DESCRIPTION

The Clinical (Coding) Reviewer is responsible for the review and interpretation of medical records to draft appeals of denied and underpaid claims. The Clinical (Coding) Reviewer reviews medical records to ensure appropriate coding of removed or revised diagnosis and procedure codes. Responsibilities include drafting appeal letters based on clinical judgment and knowledge and making coding change suggestions to our clients based on ICD-9/10 CM & PCS, CPT, HCPCS, NCCI guidance, and Coding Clinic.

RESPONSIBILITIES

• This is not an inclusive list. Other duties may be assigned dependent on client referrals.

Familiarity with and ability to identify different types of hospital documentation including, but not limited to, medical records, UB-04s, EOBs, itemized bills, hospital account notes, appeal letters, and denial/approval letters.

Review and interpret medical records to appeal denied and underpaid claims.

Apply clinical judgment and knowledge for DRG downgrades performed as a result of a Clinical Validation Review by an insurer or third-party auditor.

Draft appeal letters that are well written, logically structured, and persuasive, utilizing ICD-9/10 CM & PCS, CPT, HCPCS, NCCI guidance, and Coding Clinic.

Handle rush and high balance cases in accordance with office policy for prioritization.

Ensure that all appeals are completed timely and sent by the specified deadline.

REQUIRED QUALIFICATIONS

Licensure as a Registered Nurse (RN) or Licensed Practical Nurse (LPN/LVN)

Active CPC or CCS certification; or, in lieu of active coding certification, a minimum of 2 years of experience in a Clinical Documentation Improvement (CDI) position

Direct experience in medical record reviews/audits

Knowledge of medical coding for inpatient and outpatient claims (CPT, ICD-9/10, HCPCS) and reimbursement guidelines (MS & APR DRG, APC)

Knowledge of HIPAA laws and requirements required

Strong analytical skills and strong proficiency in Microsoft Office Tools

Excellent interpersonal, written and oral communication skills

DESIRED QUALIFICATIONS

Coding training and education experience preferred

Prior medical coding/billing experience

General understanding of hospital collections in a variety of patient care settings

CULTURE FIT

The culture at Cloudmed embraces those that demonstrate a deep passion for solving the problems of healthcare with enthusiasm for building positive working relationships and winning as a team. Take the work seriously, but don’t take yourself too seriously. Creating a strong workplace culture has been one of our staples, which we believe encourages and inspires employees to do their best. Join a fulfilling team of like-minded individuals who can get their work done, but still have fun!

BENEFITS

Cloudmed provides an extremely competitive benefit package that includes a 401(k) match, medical/dental/vision insurance and more.

Cloudmed is an Equal Opportunity Employer