Machinify

• Monitors internal and external reports and take specific actions based on the information • Responds to client correspondence and email request for information • Maintains provider information • Re-prices claims using client contracts and systems • Creates, documents, and modifies processes for new and existing clients as needed • Participates in special ad hoc projects and program initiatives as assigned • Contributes to team effort by completing assigned projects on time • Receives feedback and adjusts work priority as necessary • Performs other duties as assigned

• Work within a team as the primary point of contact for all providers, Medicare contractors, etc. • Provide professional, accurate and timely responses to CMS (Medicare) and provider inquiries. • Maintain a current knowledge of all contract requirements and objectives. • Develop professional working relationships with colleagues, healthcare providers and other Medicare contractors. • Take inbound calls from providers to answer questions and resolve complex issues. • Make outbound calls to healthcare providers to confirm if letters requesting records for review have been received. • Respond to assigned written communications from providers timely and accurately. • Educate providers on proper process protocols and their appeal rights. • Establish appropriate contacts and perform necessary research to validate provider contact information. • Conduct critical due diligence follow-ups if additional research or action is required to resolve an inquiry. • Enter and update all contact and activity information into tracking logs and the audit platform as necessary. • Research and route internal/external communications to the appropriate person or department. • Notify management of all escalated displeasure with the audit program, legal action, government intervention, escalated concerns regarding audit issues and edit parameters, and suggestions to improve or correct processes or documents. • Perform miscellaneous duties as assigned in a highly professional manner.

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records. • Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim. • Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies. • Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances. • Analyze all medication charges to determine correct pharmacy utilization and potential off-label use. • Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective. • Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions. • Review, expand, and cultivate resources to build up complex claims review content. • Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims. • Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters. • Collaborate and assist in staff training processes and development of training material as needed. • Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times. • Assists in special projects and perform other duties as needed. • Act as a subject matter expert for the overall product. • Attends all required meetings.

• Investigates and determines whether medical insurance claims are recoverable or non-recoverable from a liable third party • Communicates and negotiates with healthcare plan members, insurance adjusters, and attorneys • Utilizes computer systems to accurately document collected information • Applies organizational, analytical, and time management skills to manage daily workflow • Reviews and understands healthcare contracts • Creates medical expense spreadsheets and processes payments from recoveries

• Advises General Counsel on relevant legal issues regarding Subrogation Operations. • Provides timely and suitable legal review and advice to assigned subrogation recovery team(s). • Ensures that possible adverse suits and legal matters towards clients and Company are handled appropriately. • Provides training in relevant legal issues as assigned to new and current analysts. • Communicates with Subrogation Analysts as needed with information and guidance regarding new court decisions, statutes, and regulations and the potential impact on file handling.

• Lead discovery & technical due diligence — get to the bottom of poorly documented legacy systems (ETL, stored procedures, reporting layers, file feeds), reconstruct the business logic, and capture it in the lineage maps, mapping specs, and risk analyses everyone builds from. • Reverse-engineer complex legacy systems using agents— you will be responsible for reverse-engineering complex, undocumented legacy systems (SSIS packages, stored procedures) where business logic is embedded, not documented. You must be able to reconstruct the intent of these systems to build modern, stable equivalents. • Drive ambiguity to resolution — spot the unknowns early, own the open questions, and pull answers from clients, SMEs, and Operations instead of waiting to be unblocked. • Architect & build the migration pipelines — turn intricate legacy logic into production-grade Airflow DAGs and Spark jobs on the Machinify platform, edge cases, payer-specific carve-outs, and business-rule exceptions included, owning the full flow from ingestion through reconciliation to steady-state handoff. • Make and document the hard architectural calls — own the decisions that matter (pipeline design, partitioning strategy, validation approach) and leave a clear trail of the reasoning so others can learn from and build on it. • Prove correctness at scale — build automated reconciliation frameworks that confirm, with confidence, that migrated output matches the source down to the row. • Own the program end to end — be the single technical owner from kickoff through go-live and hypercare: scope, sequence, and track the work, surface risks before they bite, align Operations, Client Success, Platform Engineering, SMEs, and the client, and drive UAT through to sign-off. • Raise the bar for the practice — Institutionalize migration knowledge by codifying runbooks and retrospectives, mentor L3/L4 engineers to build independent capability, and turn recurring migration pain points into scalable, reusable tooling.

• Manage document workflows, including processing, quality assurance, and adherence to internal procedures. • Conduct incoming claim reviews, assign statuses, organize data, ensure accuracy, and route files to auditors. • Collaborate with internal teams to maintain the import queue, reconcile balances, validate charges, correct errors, and manage claim routing. • Oversee file intake and output, addressing discrepancies, errors, and inquiries. • Identify and report production environment issues by submitting detailed service tickets. • Analyze data trends across documents and systems, providing updates on status, claims routing, efficiency, inventory, and volume to relevant teams. • Monitor file-sharing processes, ensuring data transfer accuracy and appropriate volume levels. • Perform data entry for itemized bills. • Complete additional tasks as assigned.

• Perform detailed data quality audits to detect, troubleshoot, and resolve issues impacting accuracy and completeness. • Conduct in-depth analysis of data quality and integrity to identify and resolve issues. • Create and execute SQL queries to validate data transformations and support data analysis efforts. • Analyze and troubleshoot ETL processes and data architectures for performance and quality. • Develop, generate, and maintain client program reports, ensuring accuracy, timeliness, and alignment with client expectations and business objectives. • Perform detailed data analysis and reconciliation activities to ensure program integrity, including validating outputs against source data and expected results. • Track and analyze program performance over time, identifying variances, root causes, and trends to ensure accuracy and consistency of results. • Reconcile data across multiple sources (e.g., claims, eligibility, and reporting outputs) to ensure alignment and completeness. • Partner with internal teams to investigate discrepancies, implement corrections, and ensure accurate downstream reporting and client deliverables. • Develop, generate, and maintain recurring and ad hoc reports for both internal stakeholders and external clients, ensuring accuracy, clarity, and timeliness.

• Own the architecture, technical roadmap, and production releases for CORA, holding the team accountable for quality, reliability, and delivery pace • Stay hands-on through architectural design, code review, and selective coding where it sets the technical bar for the team • Hire, develop, and retain a team of 5–6 engineers, with deliberate investment in coaching, career growth, and performance management • Establish the engineering standards, operational practices, and delivery rhythm appropriate to an early-stage greenfield product • Guide the design of the core rules engine, the claims pipeline, and the AI innovation that moves COB determinations to be more accurate and efficient • Drive platform decisions for extensibility, scalability, and the security that regulated healthcare data demands as CORA onboards new payers • Partner with product, ML, UX, and operations to translate evolving payer and analyst requirements into scoped, sequenced work with measurable targets • Align stakeholders across teams on priorities, tradeoffs, and timelines, and drive cross-functional decisions cleanly to closure • Define and report the metrics that demonstrate engineering and product impact to leadership and to partner teams across the company • Represent the team to executive and customer audiences, presenting results and clear articulation of technical strategy

• 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 collaboratively with the audit team to identify and obtain approval for particular vulnerabilities and/or cases subject to potential abuse. • Work in partnership with our clients, CMD colleagues, and other contractors on improving medical policies, provider education, and system edits. • Keep abreast of medical practice, changes in technology, and regulatory issues that may affect our clients. • Work with the team to minimize the number of appeals; Suggest ideas that may improve audit workflows; Assist with QA functions and training team members. • Participate in establishing edit parameters, new issue packets and development of Medical Review Guidelines. • Interface with and support the Medical Director and cross train in all clinical departments/areas. • Other duties as required to meet business needs.