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 recommendations in written audit processing status codes that provide feedback to examiners used in examiner score cards, identifies error trends and training opportunities.
• Understands, interprets, and applies coding and reimbursement guidelines; provider and Health Plan contracts for professional claims to ensure accuracy.
• Audit, assess, and monitor providers and payers, including physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, independently codes and abstracts.
• Analyze inpatient and outpatient medical records using ICD‑9/ICD‑10, CPT, HCPCS, UB, and other codes, regulatory and contractual requirements, and generally accepted coding practices.
• Verify and validate c...