Remote Clinical Validation Reviewer (RN)

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. Performs DRG validation reviews, itemized bill reviews, and develops evidence-based written rationales. Collaborates with coding, payment integrity analytics, SIU, and physician advisors. Requires active RN license and at least 2 years of inpatient payment integrity medical claim review experience including DRG validation or itemized bill review.