Key Responsibilities/What You Do

• Responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication.
• Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity.
• Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy.
• Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.
• Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10),Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.
• Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
• Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
• Special focus and priority will be given to regulatory audit requirements, reports and findings.

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