Job Description

Job Description

Job Title: RN Chart Review

Location: New York, NY 10004

Shift: 9a-5p | 5x8s (HYBRID)

Position Summary:

Seeking a Registered Nurse (RN) Clinical Coder to join our Special Investigations Unit (SIU). This key role will support the identification, prevention, and investigation of healthcare fraud, waste, and abuse (FWA). The RN Chart Reviewer will analyze clinical documentation and claims data to ensure compliance, accuracy, and ethical billing practices.

Key Responsibilities:

• Review medical records and claims to assess the accuracy of coding and billing practices.
• Conduct targeted audits on high-risk claims to detect inconsistencies or violations of healthcare regulations.
• Collaborate with the SIU team to investigate suspected fraudulent activity (e.g., upcoding, unbundling, medically unnecessary services).
• Develop detailed reports outlining medical review findings, sources, rationale, and recommendations for corrective actions.
• Engage in provider communications to explain review findings and support case resolution.
• Present investigative findings to internal stakeholders and leadership.
• Support documentation preparation for audits, recoupments, compliance/legal reviews, and regulatory inquiries.
• Maintain thorough case records including findings, coding discrepancies, and provider communications.
• Stay current on changes in coding standards, regulations, and fraud detection strategies.
• Participate in special audits and projects as required.

Required Qualifications:

• RN Licensure – Active and in good standing (Required)
• AAPC or AHIMA Certification – CPC, CPMA, or CCS (Required)
• Bachelor’s degree in Nursing, Medical Billing/Coding, Healthcare Administration, or a related field
• Minimum 5 years of experience in healthcare fraud detection, auditing, or investigations
• In-depth knowledge of ICD-10, CPT, HCPCS, AMA coding guidelines
• Experience working with Medicaid, Medicare, and Marketplace/Exchange programs (Preferred)

Pride Health 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 with preferred vendors.

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