LivantaLLC

• Arbitrating/deciding payment disputes • Analyzing documentation and managing case files • Reviewing dispute-relevant information and requesting additional information as needed • Remaining neutral and writing concise determinations under deadlines • Collaborating with technical and legal professionals for appropriate decisions • Researching jurisdictional and substantive issues

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care • Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria • Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns • Uphold the highest standard of clinical integrity, neutrality, and objectivity

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care • Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria • Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns • Uphold the highest standard of clinical integrity, neutrality, and objectivity

• Serve as the primary point of contact with CMS on Program Integrity operations, including status reporting, project initiation within required timelines (10 business days), issue escalation, and delivery of Initial and Final Project Reports per SOW requirements; notify CMS within 24 hours prior to engaging external stakeholders in the absence of a Joint Operating Agreement. • Own and administer the quality assurance and inter-rater reliability process for all Program Integrity medical record reviews, including development of QA protocols, peer review assessments, and corrective action procedures; maintain a 95% or greater accuracy score each month. • Direct clinical reviewers to identify potential FWA indicators in medical records, including falsified documentation, altered records, billing pattern anomalies, medically unnecessary services, and evidence of patient harm; ensure review findings are documented consistent with CMS and FIG standards. • Directly supervise and manage the clinical review team (RN, LPN, coder, and support staff), including hiring, onboarding, performance management, workload distribution, and ongoing training. • Analyze Medicare claims data and medical record documentation to identify FWA patterns, billing anomalies, provider-specific trends, and program vulnerabilities; develop lead recommendations and supporting data for submission to CMS for consideration of additional review projects or referrals. • Maintain current working knowledge of Medicare coverage rules, CMS Program Integrity Manual (IOM 100-8), Unified Case Management (UCM) system procedures, UPIC coordination protocols, and applicable law enforcement referral standards governing fraud-focused medical review activities. • Lead the Program Integrity medical review workstream, including coordination with UPICs, law enforcement agencies, state agencies, and other external stakeholders as directed by CMS; ensure all referrals, overpayment recoupments, and field work are executed in compliance with SOW requirements and FIG protocols.

• Conduct all mandatory case review and quality assurance activities • Assure the efficiency of the case review process • Communicate with and support physician reviewers • Edit documentation for internal and external dissemination • Develop and maintain working relationships with community agencies

• Conduct an initial assessment of documentation from both the initiating and responding parties. • Review submitted documentation to identify missing documents and determine what is required to resolve the dispute. • Follow procedures to obtain the appropriate documentation. • Determine the appropriate type of clinical reviewer necessary to complete the case, such as a medical coder or a physician. • Prepare documents for the arbitrator reviewer assigned and provide instructions as needed. • Collaborate with the legal team to facilitate resolution of disputes. • Draft professional determination correspondence. • Perform quality assurance checks on determinations according to Federal or State guidance. • Audit and analyze patient records to ensure appropriate determination. • Stay current with regulation changes and perform research on a case-by-case basis. • Deliver high-quality, professional determinations free of grammar and spelling errors. • Amend reports with additional clinical information when necessary. • Participate in an interdisciplinary health care team to achieve positive outcomes.

• Conduct independent, remote case reviews evaluating medical necessity, appropriateness, or quality of care. • Provide evidence-based assessments and written determinations following established clinical guidelines and review criteria. • Support case types including: Utilization review, Appeals and hearings, Quality of care and standard of care concerns. • Uphold the highest standard of clinical integrity, neutrality, and objectivity.

• The Nurse Educator/Review Coordinator’s primary role is to facilitate provider education related to the claim reviews performed under Task Order 3 for the BFCC-QIO contract. • The education provided will be dependent on the outcome of the reviews and may involve the application of Medicare policy, ICD-10-CM/PCS coding rules, DRG assignment, medical necessity, or other related claim review topics. • Collaborate with staff, management, and the Medical Director to identify billing issues that could improve with provider education. • Provide recommendations related to problem identification and proposed resolutions. • Stay current on the latest evidence for new practices and quality indicators through learning activities, in-services, and information sharing. • Uphold policies, procedures, and standards. • Assist management with assessing staff competencies and needs for training. • Assist management with the inter-rater reliability or other QA processes. • Facilitate education sessions with providers on CMS-required medical record documentation for claim reviews. • Facilitate the construction of final claim review provider letters. • Promote activities to improve provider compliance. • Serve as a liaison between the provider and the QIO. • Perform desktop medical review. • Interpret and apply review criteria as applicable to specific positions. • Communicate with and support physician reviewers by summarizing case facts, preparing case questions, and assisting with resolving issues requiring physician input. • Provide for the dissemination of current information necessary for the successful implementation of contract expectations. • Provide feedback to Managers to assist with evaluation of staff. • Maintain records/data related to job activities and duties. • Protect the confidentiality of patient information through compliance with the Health Insurance Portability and Accountability Act (HIPAA) and the Health Information Technology for Economic and Clinical Health Act (HITECH).

• The HSCRC Coding Reviewer will be a subject matter expert in clinical documentation review, clinical data abstraction, clinical coding, auditing, and variables impacting HSCRC payment methodologies that are based in medical record documentation. • Performs compliance audits employing specified protocols and criteria; conducts data abstraction and collection activities; interprets and applies coverage and payment policies, edits, and certification and regulatory requirements for medical necessity and other audit decisions; classifies findings and provides commentary for clinical data, qualitative, and statistical analyses; records rationale for and basis of audit findings using proper grammar and communication methods; writes reports in accordance with company requirements. • Provides feedback to hospitals concerning audit findings and discusses rationales for audit decisions. • Performing audit functions for the HSCRC Inpatient/Outpatient Data Abstract Review Contract in a timely and accurate manner. • Generating well-written deliverables and audit work papers. Outstanding verbal communication skills. Outstanding communications and interactions with hospital and client personnel.

• Own program execution against contract milestones, deliverable schedule, resource management and performance standards across both autonomous coding and denials management workstreams • Lead kickoff, quarterly in-process reviews, governance forums, and stakeholder engagement activities including site visits to DHA facilities and pilot MTFs • Provide executive-level risk identification, escalation management, and corrective action planning • Drive cross-functional coordination between technology, data, clinical coding, revenue cycle, cybersecurity personnel • Oversee development and maintenance of all programmatic deliverables • Build and maintain positive working relationships with government stakeholders, manage expectations, and foster cross-organizational collaboration • Champion change management and user adoption across coder, revenue cycle, and clinical leadership communities • Ensure contractor compliance with DoD and DHA security, privacy, personnel, and reporting requirements