All Care To You

• Provide a functional manager role for all QA reporting data staff. • Conduct QA reviews and test work items before user acceptance testing and final approvals by key stakeholders. • Prioritize work items and requests from key stakeholders. • Create and update Azure DevOps board tickets to improve reporting automation for manual steps. • Identify any data quality/process improvement points, and create new or update SQL queries and stored procedures. • Develop, implement and oversee the use of data analysis and quality assurance tools. • Establish data quality standards (units, variable names) and develop policies and procedures for higher quality. • Analyze QA data to identify root causes of quality issues, track metrics, and predict future trends. • Design and implement data testing procedures, validating datasets and identifying inconsistencies. • Build and maintain reporting master document for each health plan and report by lines of business. • Document will need to be maintained as additional instruction or clarification is received. • Review all currently implemented compliance reporting technical specification documents and report template instructions to ensure current reporting logic and data definitions align with those requirements. • Document will need to be maintained once created as new reports as requested by the health plans. • Review all compliance report output to make sure the data aligns with the templates, all required information is complete, and data is in the correct format for each field. • Check all compliance reports to confirm all ran on time and without error. • Run any compliance reports manually ad-hoc as needed. • Creates SOPs and documentation for running each report manually. • Complete any manual steps to correct or make reports accurate. • Identifies and corrects corrupt or inaccurate records. • Drive process improvement of quality across all deliverables. • Running data queries to identify coding issues and data exceptions, as well as cleaning data. • Revise our procedures and documentation that govern our internal and external policies and processes. • Investigate and resolve questions and issues raised by audit activities. • Other duties as needed.

• Conducts timely and accurate follow-up on professional services claims to ensure all requested information has been submitted and claims are being processed utilizing payor portals, secure chat, secure messaging, and telephone calls • Identifies missing payments from the health plan and initiates tracking procedures • Reviews incoming correspondence from health plans and takes appropriate action or escalates to designated team members as needed • Identifies pending claims and determines next steps required to obtain reimbursement for claim • Uses existing queries to review limited new denials for processing errors, appropriately assigns a status based on review, corrects any internal errors and resubmits claims as necessary • Follows up with insurance carriers, providers, or other stakeholders to gather additional information or documentation required for claims resolution • Monitors incoming messages from providers and responds to the provider or escalates the request to the appropriate team member • Identifies claims with more complex issues and escalate them to the appropriate team member for resolution as needed • Research health plan reimbursement policies and procedures, clinical guidelines, coding, and CCI edits to ensure claims are billed appropriately • Communicate effectively with insurance companies, healthcare providers, and their billing staff to resolve claims issues and answer inquiries • Document all interactions and updates in the claims management system • Maintain accurate records of claim status, actions taken, and resolutions utilizing established policies and procedures • Prepare and submit reports on claim follow-up activities and status updates to management as requested • Ensure all claims follow-up activities comply with company policies, industry regulations, and legal requirements • Stay updated on changes in insurance policies, regulations, and industry standards • Must meet quantitative production standard of working 100 – 150 claims per week • Attend departmental and company meetings as required • Identify and report trends which could have an overall negative impact on claim payments such as processing errors, denials, or billing issues • Investigate and resolve discrepancies or issues related to claims processing and payment • Work with other team members and departments ensure proper claim submission • Identify and recommend process improvements to enhance the efficiency and effectiveness of the claims follow-up process • Participate in training and development opportunities to stay current with best practices and industry trends

• Coordinate and oversee the care of patients receiving outpatient medical services. • Identification of members appropriate for case management, based on identification of health-related problems. • Assessing members physical and psychosocial needs/barrier. • Developing the case management care plan. • Developing and implementing the interventions needed to resolve barriers and coordinate care. • Documenting assessments, care plan interventions, and all other activities related to coordinating the care of the case managed members. • Maintain client privacy, safety, confidentiality, and advocacy while adhering to ethical, legal, regulatory and accreditation standards. • Maintain department procedure/policy standards with regards to turnaround time, etc. • Support the interdisciplinary team approach to ensure effective resource utilization, as well as quality and cost-effective outcomes. • Coordinate resources for members. • Document all case management activities in the Ezcap system. • Utilize reports and systems to identify and monitor utilization patterns and facilitate needed care coordination. • Attend Interdisciplinary meetings and team meetings. • Manage the cases to include case management and transition of care activities.

• Support the Managed Service Organization (MSO) by performing detailed medical claims reviews to ensure accuracy, compliance, and appropriate reimbursement across Medicare, Commercial, and Medicaid lines of business. • Focus on validating diagnosis and procedure coding, identifying improper billing or documentation, and supporting medical necessity determinations in alignment with CMS and payer-specific guidelines. • Serve as a key liaison between care management and claims operations to promote coding accuracy and support efficient payment processes within value-based care arrangements. • Review provider medical records to validate the following claim data: Codes billed are accurate, complete, and comply with MSO and payer policies; Codes billed comply with bundling and unbundling guidelines and global period policies; ICD-10 codes are chosen appropriately and to the highest level of specificity; CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards; Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules. • Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance. • Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors. • Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials. • Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity. • Stay current on updates to CMS regulations, payer billing policies, and industry coding changes. • Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards.

• Processing and/or adjusting and releasing of hospital or medical claims according to established policies and procedures. • Identifying procedural and system inefficiencies and working with the appropriate entities to resolve issues. • Performing research, analysis, reporting and special projects as assigned. • Meeting production requirements and quality standards. • Participating in claims workflow projects. • Creating and running Crystal /SQL reports for distribution to claims examiners. • Processing claims for all lines of business including complex claims. • Complying with all Company and Department Policies and Procedures. • Assisting in claims audit preparation/activities, when needed. • Validating the diagnosis and procedure codes against the authorized services on Inpatient claims. • Resolving Provider Disputes (PDR’s) and documenting for required Acknowledgement and Resolution Letters. • Requesting additional information required to adjudicate claims, by correctly coding claims notes. • Accurately coding claims notes to generate Denial Letters for claims denied as member liability. • Resolving claims issues on identified processing errors and making recommendations for improvements. • Identifying any overpayment/underpayment in a review and or history search. • Following department protocol for reporting and following up. • Adjusting voids and reopening claims within guidelines. • Resolving grievances and complaints received through Customer Services. • Supporting the Claims Department as business needs require. • Assisting with training of team members, if needed. • Working without significant guidance and identifying claims payment errors and/or system configuration flaws during day-to-day operation.