This role focuses on reviewing inpatient clinical documentation and coding to support accurate, compliant medical record validation. The work centers on collaborating with coding and clinical teams to assess documentation quality, identify discrepancies, and help ensure appropriate reimbursement and reporting. It is a nonclinical, remote-friendly nursing role for an RN with inpatient coding experience.
Key Responsibilities
- Conduct clinical validation reviews of inpatient records to support coding accuracy and documentation integrity.
- Identify documentation gaps, inconsistencies, and clinical indicators that affect code assignment and reimbursement.
- Coordinate with coding, case management, and other clinical teams to clarify documentation and resolve review findings.
- Use clinical judgment and coding knowledge to evaluate diagnoses, procedures, and medical record support.
- Document review outcomes, rationale, and recommendations in accordance with organizational and compliance standards.
- Participate in quality improvement activities related to inpatient documentation and coding practices.
Required
- Current RN licensure.
- Inpatient coding experience.
- Clinical background with experience reviewing medical records and supporting documentation validation.
Preferred
- Experience working in a managed care or payer environment.
- Familiarity with clinical documentation improvement or medical coding workflows.
- Experience collaborating with cross-functional clinical and coding teams.
Benefits & Perks
- Remote work structure.
- Opportunity to work in a clinical validation and documentation review role.
- Collaboration with multidisciplinary clinical and coding teams.