Review and inspect operational claim processes and adjudication to apply quality standards.
Create clear audit findings and recommendations in written audit processing status codes, provide feedback to examiners used in examiner score cards, and identify error trends and training opportunities.
Understand, interpret, and apply coding and reimbursement guidelines; provider and health plan contracts for professional claims to ensure accuracy.
Audit, assess, and monitor providers and payers (physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc.), including independent coding and abstraction of medical records.
Analyze inpatient and outpatient medical records using ICD-9/ICD-10, CPT, HCPCS, UB, and other codes, ensuring compliance with regulatory and contractual requirements.
Verify and validate claims documents received through multiple channels, ruling out documentation/cod...
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