Remote Clinical Validation Reviewer (RN)

JOB DESCRIPTION Job Summary Provides support for inpatient and outpatient clinical claim review activities. Verifies that coded diagnoses, procedures, revenue codes, and corresponding reimbursement methodologies accurately reflect the member's documented clinical condition, services rendered, and billed charges. Assesses medical records for clinical accuracy, acuity alignment, and documentation integrity. Identifies inconsistencies that impact reimbursement such as unsupported diagnoses, incorrect procedure coding, or inaccurate revenue code assignment and determines whether billed services meet coding and billing guidelines, payer policy, and regulatory requirements. Contributes to overarching strategy to provide quality and cost-effective member care. Essential Job Duties • 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 condit...