Simsy Ventures

• Analyze and process a variety of complex medical claims in accordance with program policies and procedures, ensuring accuracy and compliance. • Adjudicate claims according to program guidelines, applying critical thinking skills to navigate complex scenarios. • Ensure prompt claims processing to meet client standards and regulatory requirements. • Identify and resolve any barriers using effective problem-solving strategies. • Collaborate with internal departments to proactively resolve discrepancies and issues. • Use analytical skills to identify root causes and implement solutions. • Uphold confidentiality of patient records and company information in accordance with HIPAA regulations. • Maintain thorough and accurate records of claims processed, denied, or requiring further investigation. • Analyze and report trends in claim issues or irregularities to management. • Assist Team Leads with reporting to contribute to continuous process improvements. • Engage in audits and compliance reviews to ensure adherence to internal and external regulations. • Critically evaluate and recommend process improvements when necessary. • Mentor and train new claims processors as needed.

• Conduct objective medical case reviews using standardized assessment criteria • Evaluate the timeliness and appropriateness of care provided • Identify quality improvement opportunities • Review cases initiated for non-standardized performance improvement reasons • Assess medical decision-making and compliance with best practices • Provide expert medical opinions • Analyze complex clinical scenarios from an impartial, evidence-based perspective

• Manage and ensure the accuracy and timeliness of Medicare cost report acceptance, tentative and straight-to-final settlements, interim rates, and applicable limits for all providers in the Fiscal Intermediary Shared Systems (FISS) • Process cost report correspondence, including mail, cost report submissions, and settlement documentation (tentative and final) • Analyze cost report documentation to determine whether acceptability criteria are met for submission • Update systems such as FISS and STAR with application data from Provider Enrollment • Maintain system accuracy by updating rate changes based on payment rate reviews, provider reviews, and CMS-mandated changes • Build constructive working relationships with internal teams, clients, and customers to meet shared goals • Collaborate with departments such as Recoupment, Systems Support, Provider Call Center, Provider Audit, Provider Enrollment, PreProcess, and Provider Education to resolve provider issues • Respond to provider inquiries regarding payments, cost reports, and reimbursement-related topics • Mentor and support onboarding and development of new and existing staff • Collaborate with team members to achieve departmental goals and ensure timely task completion • Contribute to a positive team environment through feedback, process improvement, and participation in team goals

• Review assigned TEFCA directory entries against authoritative corroboration sources, including NPPES, CMS Provider of Services data, IRS Tax-Exempt Organization Search, RCE/QTF published documentation, and QHIN-provided records. • Apply the approved Task 2 Review Methodology and Control Framework to each assigned entry. • Follow documented decision criteria to classify directory entries as: • T1: Pass • T2: Minor discrepancy • T3: Inexplicable discrepancy • T4: Non-compliant • Research, validate, and reconcile healthcare directory data across multiple reference sources. • Document review findings, evidence, discrepancies, and final dispositions in Jira with a complete audit trail. • Ensure no entry is closed without a recorded disposition and supporting documentation. • Escalate exception-path entries to the Lead Analyst for adjudication. • Flag entries requiring QHIN outreach or additional review. • Participate in Blind QA sampling and quality review activities as assigned. • Maintain consistent review throughput to support weekly and biweekly reporting deadlines. • Support a disciplined, accurate, and repeatable review process across high-volume data sets.

• Conduct objective medical case reviews using standardized assessment criteria • Evaluate the timeliness and appropriateness of care provided • Identify quality improvement opportunities • Review cases initiated for non-standardized performance improvement reasons • Assess medical decision-making and compliance with best practices • Provide expert medical opinions

• Conducting pre- and post-payment medical reviews to ensure compliance with established clinical criteria and guidelines • Assessing medical necessity, appropriateness, and reimbursement eligibility while documenting decisions • Reviewing medically complex claims, pre-authorization requests, appeals, and fraud/abuse referrals • Educating internal and external teams on medical review processes, coverage determinations, and coding requirements • Supporting quality control activities to meet corporate and team objectives • Providing guidance to LPN team members and supporting non-clinical staff through training and discussions • Assisting with special projects and additional responsibilities as assigned

• Serve as the primary liaison to the Government on all contract issues and policy matters, coordinating with the CMS Contracting Officer (CO) and Contracting Officer’s Representative (COR). • Lead the post-award Kick-Off Meeting and orientation briefing within seven (7) business days of award, addressing management approach, project work plan, staffing, communications, risk management, and configuration management. • Develop, maintain, and execute the Project Management Plan and Integrated Master Schedule (IMS), revising the work plan no more frequently than monthly as project conditions evolve. • Manage project staff and any subcontractors to meet timelines established for both standard and expedited review of Eligibility Determinations and Payment Determinations. • Ensure timely delivery of high-quality deliverables, including the Audit Strategy, Audit Roadmap, individual audit reports, the Preliminary and Final Annual Audit Reports, and the Operational Readiness and Transition Report. • Advise CMS in a timely manner of any difficulties arising from contract administration, including sudden increases in inquiry or appeal volume and the team’s ability to absorb workload challenges; manage project costs. • Provide quality assurance on all draft audit reports to ensure sufficient rationale is documented for every audit decision. • Lead recruiting, retention, onboarding, and replacement of qualified personnel; scale resources in response to evolving audit volumes and program needs. • Oversee subcontractor performance and cost controls, ensuring that any use of subcontractors and consultants is selective, strategic, and does not increase project cost. • Own the contractor’s Quality Control Plan and continuous improvement processes; use performance data to refine processes during Phase 1 and support the transition to Phase 2. • Safeguard sensitive healthcare information and ensure all work complies with the No Surprises Act, the Federal IDR regulations at 45 CFR 149.510, applicable HHSAR clauses, and all contract security and privacy requirements.

• Serve as the primary liaison to the Government on all contract issues and policy matters, coordinating with the CMS Contracting Officer (CO) and Contracting Officer’s Representative (COR). • Lead the post-award Kick-Off Meeting and orientation briefing within seven (7) business days of award, addressing management approach, project work plan, staffing, communications, risk management, and configuration management. • Develop, maintain, and execute the Project Management Plan and Integrated Master Schedule (IMS), revising the work plan no more frequently than monthly as project conditions evolve. • Manage project staff and any subcontractors to meet timelines established for both standard and expedited review of Eligibility Determinations and Payment Determinations. • Ensure timely delivery of high-quality deliverables, including the Audit Strategy, Audit Roadmap, individual audit reports, the Preliminary and Final Annual Audit Reports, and the Operational Readiness and Transition Report. • Advise CMS in a timely manner of any difficulties arising from contract administration, including sudden increases in inquiry or appeal volume and the team’s ability to absorb workload challenges; manage project costs. • Provide quality assurance on all draft audit reports to ensure sufficient rationale is documented for every audit decision. • Lead recruiting, retention, onboarding, and replacement of qualified personnel; scale resources in response to evolving audit volumes and program needs. • Oversee subcontractor performance and cost controls, ensuring that any use of subcontractors and consultants is selective, strategic, and does not increase project cost. • Own the contractor’s Quality Control Plan and continuous improvement processes; use performance data to refine processes during Phase 1 and support the transition to Phase 2. • Safeguard sensitive healthcare information and ensure all work complies with the No Surprises Act, the Federal IDR regulations at 45 CFR 149.510, applicable HHSAR clauses, and all contract security and privacy requirements.

• Ensure audits are performed in a consistent, impartial, and objective manner across all certified IDR entities. • Supervise project audit teams, including assignment of work, mentoring, and review of junior auditors’ output. • Manage and execute completion of assigned tasks within established timelines for standard and expedited audits. • Provide quality control over audit workpapers, evidence, findings, and recommendations to ensure each audit is well-documented and defensible. • Review the project team’s audit work, including documentation supporting eligibility and payment determination findings, and the rationale documented in draft audit reports. • Provide technical assistance to CMS and project staff on audit methodology, including statistically representative sampling design, treatment of single vs. batched disputes, handling of reopened determinations, and assessment of clerical, procedural, or jurisdictional errors. • Review audit reports and other deliverables and interact with the client on program and technical issues, including the Audit Strategy, individual audit reports, and the Preliminary and Final Annual Audit Reports. • Apply knowledge of Generally Accepted Accounting Principles (GAAP), Government Auditing Standards (GAS), and applicable Federal regulations — including guidelines, standards, and concepts — and other relevant industry practices to each engagement. • Assess certified IDR entity compliance with eligibility determination requirements (including batching, State All-Payer Model Agreements, and specified State law applicability), payment determination procedures, recordkeeping, and reporting timeframes. • Identify recurring issues, emerging trends, and “red flags” for escalation; support calculation of financial impact (e.g., collected but unremitted administrative fees) where applicable. • Safeguard sensitive healthcare information and ensure audit execution complies with the No Surprises Act, 45 CFR 149.510, and all contract security and privacy requirements.

• Conduct objective medical case reviews using standardized assessment criteria • Evaluate the timeliness and appropriateness of care provided • Identify quality improvement opportunities • Review cases initiated for non-standardized performance improvement reasons • Assess medical decision-making and compliance with best practices • Provide expert medical opinions • Analyze complex clinical scenarios from an impartial, evidence-based perspective