Clinical Nurse Specialist

Title: Clinical Nurse Specialist 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.