Auditing claims for medically appropriate services provided in both inpatient and outpatient settings while applying appropriate medical review guidelines, policies and rules. Document all findings referencing the appropriate policies and rules. Generate letters articulating audit findings. Supporting your findings during the appeals process if requested. Working collabor

Responsible for the review and update of existing concepts based upon required periodic review cycle or as needed based upon client or regulatory changes (research, analysis, update rule documents, code lists and edits accordingly). Collaborates with and leverages Segment Specialist expertise to ensure on point results. Ensure training material updates (may develop or coo

ly and accurately conduct coding reviews on medical records for assigned client audit contract in accordance with the statement of work while meeting compliance, productivity, and quality expectations. Conduct review of flagged claims and Fraud Waste & Abuse (FWA) referrals involving suspected upcoding, unbundling, anomalous coding, intentional miscoding, etc. Timely revie

Determines and facilitates appropriate action for claim resolution and correct financial responsibility via DOFRs, IPA and health plan/IPA contacts. Effectively uses detailed documentation in EMR and/or billing system(s) of all activities undertaken. Maintains timely follow up on outstanding insurance claims in appropriate EPIC WQs, ensuring claims are billed/rebilled wit