Review high-complexity claims and denials with advanced clinical judgment.
Determine admission type, level of care, and length of stay per docs and payer rules.
Apply CMS, InterQual, MCG, LCD/NCD policies and payer standards.
Perform line-item reviews to ensure accuracy and reimbursement integrity.
Review DRG assignments and identify opportunities for appeal.
Document clinical rationale and recommendations with supporting evidence.

🎯 Requirements

Active RN license with ADN or BSN; Compact licensure preferred.
2+ years in medical necessity, admissions/LOS, LCD/NCD, DRG, and line-item reviews.
3-5 years acute care experience in ICU/Trauma, Surgery, Orthopedics, or Neurosurgery.
Strong knowledge of payer policies and CMS guidelines.
Excellent written and verbal communication skills.
Proficient with Excel/Outlook; familiarity with EMR/EHR systems.

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