Job Description

Job Description:

Title: Clinical Nurse Specialist Remote

REQUIRED: ACTIVE RN LICENSE (multi-state preferred)

Key Responsibilities:

• Perform clinical coding and DRG validation for various service types.
• Review claims for accuracy and severity of stay based on appropriate diagnosis codes.
• Apply CMS guidelines, state policies, and payer requirements in coding processes.
• Support appeals and reconsiderations, including Medicaid-related cases.
• Collaborate with vendors and internal teams on coding and editing systems.
• Ensure compliance with coding certifications and payer policies.

Qualifications:

• Active RN license (multi-state preferred) OR Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), CPC, CSS, RHIT, or equivalent credential.
• Minimum 3 5 years of experience in clinical coding and DRG validation.
• Strong knowledge of CMS guidelines, payer policies, and therapy benefit structures.
• Experience with reconsiderations, appeals, and code editing (CPC experience preferred).
• Medicaid experience strongly preferred.
• Ability to teach systems and code editor tools; prior coding experience required.

Preferred Skills:

• Familiarity with state-specific coding policies and written guidelines.
• Knowledge of all service types and payer structures.
• Strong analytical and organizational skills.
• Years of Experience:3.00 Years of Experience

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