Opportunity Description
Responsibilities
- Support complex medical record audit programs, dispute management, and escalation management.
- Generate in-depth reporting and analysis for Pre-Pay and Post-Paid processes to track performance.
- Provide production and progress reports to management and recommend resolutions to increase team performance.
- Mentor Program Integrity Audit Analysts and identify training opportunities to close knowledge gaps.
- Use CPT, ICD10, HCPCS, DRG, and REV coding rules to analyze complex provider claim submissions.
- Research and interpret state-specific Medicaid, federal Medicare, and ACA/Exchange laws and guidelines.
- Make claim audit payment decisions for highly complicated scenarios using medical coding guidelines.
- Refer suspected Fraud, Waste, or Abuse (FWA) to the Special Investigations Unit (SIU).
- Collaborate with cross-departmental teams including Claims, Configuration, and IT to address system gaps...
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