• Performing physical and remote audits of insured’s business • Interviews, investigates, collects, and records information to be used in a written report that is provided to the insurance carrier.

• Conduct insurance policy audits for Worker’s Compensation, Auto and General Liability policies. • Audit the policyholder’s records according to client company standards. • Schedule appointments with the insured to be audited and obtain necessary documentation for insurance company client audits.

• Conduct routine and focused coding audits across multiple medical specialties (e.g., cardiology, orthopedics, general surgery, gastroenterology, radiology, internal medicine, etc.). • Review CPT®, ICD-10-CM, and HCPCS Level II coding for accuracy, completeness, and compliance with CMS, OIG, and payer-specific rules. • Evaluate medical record documentation to ensure accurate code assignment and adherence to medical necessity and coding guidelines. • Identify trends, patterns, and recurring coding errors; collaborate with coders and leadership to implement corrective actions. • Prepare detailed audit reports summarizing findings, accuracy rates, and recommendations for improvement. • Provide one-on-one or group coder education and feedback based on audit outcomes. • Assist in the development and maintenance of internal audit tools, policies, and training materials. • Stay current on coding updates, compliance regulations, and industry best practices. • Participate in internal compliance reviews and support external audits as needed. • Contribute to process improvement initiatives that enhance coding quality and operational efficiency.

• 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.