MedReview Inc.

• Responsible for reviewing data in the review application and client claim processing system, and comparing with corresponding UB, medical record or other documentation. • Responsible for reviewing all necessary documentation as necessary to determine appropriate reimbursement for a claim. • Responsible for reviewing adjudication software system’s claim and line items for determination of how to price a claim / line item. • Possess ability to work at a computer for extended periods. • Other duties as assigned.

• Assist Appeals leadership with daily administrative work within the department. • Perform research, investigation, and analysis of appeals, grievances, and other types of complaints filed by providers and clients to administer timely resolution. • Perform responsibilities for all aspects of nonclinical appeals and inquiries. • Prepare and disseminate case file for External Reviews and/or State Fair Hearing. • Manage and monitor all appeals from Non-Participating providers. • Independently prepare well written, customized responses to all provider inquiries/complaints that appropriately and completely address the complainant’s issues and are structurally accurate. • Ensure timely review, research, and resolution of appeals, grievances, and complaints within guidelines. • Consult with managers on problem cases and interface with clinical supervisors, account managers, and other personnel in resolving health plan requests or provider inquiries. • Log and track grievances, appeals, and other types of complaints as needed. • Review and determine outcome of appeal/grievance, either independently or in conjunction with clinical appeal staff. • Consult with subject matter experts and resources available within organization to assist in appeal and complaint resolution. • Make critical decisions regarding research and investigation to appropriately resolve all inquiries. • Serve as a liaison to Appeal Coordinator providing guidance and expertise to ensure timely resolution of cases.

• Serve as the primary SNF domain expert for the product development team by translating regulatory and clinical requirements into audit rules, workflows and operational processes. • Validate and refine SNF audit methodology, including medical necessity criteria, documentation standards and coding requirements. • Define MVP scope, roadmap enhancements and implementation readiness. • Apply deep knowledge of CMS SNF regulations, PDPM, MDS/RAI, therapy documentation and state Medicaid policies. • Monitor regulatory updates and recommend product adjustments as needed. • Define and validate claim selection logic, risk indicators and scoring models. • Develop and validate end-to-end workflows, including intake, clinical review, provider outreach and appeals. • Define SLA expectations for turnaround times, provider response windows and internal review cycles. • Support training for clinical reviewers, auditors and provider engagement teams. • Define reporting needs for audit outcomes, savings, provider trends and operational KPIs. • Partner with analytics to ensure dashboards and reporting tools are accurate and actionable. • Identify opportunities for continuous improvement based on audit results. • Serve as SME during product implementation, ensuring all components are ready for deployment.

• Perform DRG Clinical Validation reviews to ensure diagnoses are accurate, supported, and compliant • Evaluate medical records, diagnostic findings, and treatment plans using evidence-based guidelines • Produce clear, concise clinical summaries and determinations within established turnaround times • Identify opportunities for improved documentation, coding accuracy, and cost containment • Conduct readmission and level of care reviews, including outlier and appeal cases • Collaborate with internal teams and, when needed, engage with providers to support clinical findings • Contribute to quality assurance initiatives and ongoing program development.

• Conduct thorough data audits to ensure accuracy in claims processing and resolution. • Analyze large datasets to identify patterns, discrepancies, and trends related to claims performance. • Work closely with team members to share insights, collaborate on problem-solving, and contribute to discussions regarding claims audits. • Resolve claims discrepancies by determining whether claims are underpaid or overpaid, providing clear documentation of findings. • Maintain high standards of accuracy and efficiency while following established leadership guidelines. • Prepare and present audit findings and recommendations to leadership in a clear and concise manner.

• Design, develop, and maintain efficient data models and ETL/ELT processes • Write complex SQL queries and ClickHouse functions • Utilize Python for data cleaning, transformation, and automation of BI tasks • Create interactive dashboards and reports using BI tools • Translate stakeholder needs into actionable BI solutions • Ensure data accuracy, integrity, and security • Collaborate with clinicians and operational leaders • Perform deep-dive analyses to support strategic decision-making

• Design, implement, and maintain end-to-end data pipelines on Azure, ensuring high availability and low latency for healthcare claim and analytics processing. • Manage and optimize ClickHouse as our primary analytical engine. • Structure data environments to support the full ML lifecycle. • Collaborate with Data Scientists to implement automated CI/CD pipelines for model deployment, monitoring, and retraining. • Develop scalable frameworks to ingest diverse healthcare data sources with high velocity. • Ensure all data structures and processes adhere to HITRUST/HIPAA standards.

• Conduct thorough data audits to ensure accuracy in claims processing and resolution. • Analyze large datasets to identify patterns, discrepancies, and trends related to claims performance. • Work closely with team members to share insights, collaborate on problem-solving, and contribute to discussions regarding claims audits. • Resolve claims discrepancies by determining whether claims are underpaid or overpaid, providing clear documentation of findings. • Maintain high standards of accuracy and efficiency while following established leadership guidelines. • Prepare and present audit findings and recommendations to leadership in a clear and concise manner.

• Collaborate with stakeholders to identify business challenges that can be solved through data analysis. • Gather data from various sources (SQL databases, APIs, web scraping), then clean and "wrangle" it to ensure accuracy for modeling. • Design and implement algorithms and predictive models using machine learning techniques to forecast outcomes or categorize information. • Analyze datasets to uncover hidden patterns, trends, and anomalies. • Translate technical findings into "data stories" using tools like Tableau or Power BI to influence executive decisions.

• Collaborate with ML engineers and data platform teams to design, implement, and maintain the feature store architecture for both offline (batch) and online (real-time) use cases. • Identify, define, and engineer high-quality features from various raw data sources (databases, APIs, streaming data) using statistical analysis and domain knowledge. • Partner with database administrators, clinical experts, data scientists, ML engineers, and business stakeholders to promote feature reuse, define governance standards, track feature lineage, and ensure data consistency across models. • Build and optimize ingestion and transformation pipelines using distributed data frameworks to populate the feature store, ensuring data accuracy, reliability, and freshness. • Generate training and testing datasets from the feature store and work with ML engineers to ensure seamless feature serving for model inference in production environments. • Develop monitoring and alerting frameworks to track feature data quality, integrity, and latency, proactively identifying and resolving issues. • Document feature definitions, data sources, and usage best practices, and effectively communicate complex technical concepts and insights to technical and non-technical audiences.