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 claims...
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