JOB DETAILS

1. Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/diagnosis codes, CMC guideline along with referring to client specific guidelines and member policies
2. Adhere to the state and federal compliance policies and contract compliance

3. Assist the prospective team with special projects and reporting

4. This process works on identifying discrepancies between medical records and billed services

5. Identifying Up-coding, Duplication, and Misrepresentation of services

6. Managing and reporting adverse events and serious adverse events

7. Reviewing clinical study protocols, reports and study documentations

8. Supervising the study drug administration and the activities carried out by other clinical staff

9. To conduct clinical examination of all subjects participating during all clinical studies

10. To write and revise SOP...