Job Title: RN Chart Reviewer

Location: New York, NY 10041

Schedule: 5X8

Shift: Days

Pay Range: $2000- $2200weekly

Key Responsibilities:

• Perform detailed medical record reviews to validate clinical documentation and coding accuracy.
• Evaluate diagnosis and procedure coding across various medical documents, including consultation reports, operative reports, progress notes, and discharge summaries.
• Conduct audits of high-risk claims and billing patterns to ensure adherence to healthcare regulations and MetroPlusHealth policies.
• Identify and report cases of potential FWA, including over-utilization, upcoding, and non-medically necessary services.
• Collaborate with SIU investigators and analysts on clinical assessments of suspicious claims.
• Develop comprehensive reports with clinical rationale, findings, and recommendations for corrective actions, including claim denials or recoupments.
• Participate in provider discussions to explain audit findings and ensure clear understanding of clinical determinations.
• Present audit findings and clinical insights to leadership and other stakeholders to support FWA case development.
• Maintain thorough and accurate documentation of reviews, clinical findings, coding issues, and provider communications.
• Support the preparation of documentation for compliance, legal, and regulatory reviews.
• Remain current on evolving clinical guidelines, coding standards (ICD-10, CPT, HCPCS), and fraud detection practices.
• Participate in special projects, ad hoc audits, and other assignments as required.

Education and Certifications:

• Active, unrestricted RN license in New York State required.
• 3+ years of clinical experience, preferably in acute or managed care settings.
• 2+ years of experience in medical record review, coding audits, or SIU/Utilization Review work.
• Familiarity with coding systems including ICD-10, CPT, and HCPCS.
• Strong understanding of CMS and Medicaid billing guidelines, medical necessity criteria, and healthcare compliance standards.

Interested? Apply now!

About Pride Health:

Pride Health is Pride Global's healthcare staffing branch, providing recruitment solutions for healthcare professionals and the industry at large since 2010.

Pride Global offers eligible employee’s comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts.

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