• 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.

• Lead, support and report independent GCP/PV audits according to the NVS Quality System and the current GCP/PV regulations to assess compliance with applicable regulations, standards, and guidance documents. • Review and approve corrective action plans in support of the audit observations, ensuring alignment with strategic direction of the company. • Assist in driving implementation of the applicable actions. • Travel up to 60% of time. • Support the strategic development of an effective global risk-based audit strategy and programme. • Collect, collate and incorporate input into audit strategy and plan. • Conduct, document and follow-up of global quality regulatory compliance audits and assessments of GPvP according to specified requirements.

• Lead, support and report independent GCP/PV audits according to the NVS Quality System and the current GCP/PV regulations to assess compliance with applicable regulations, standards, and guidance documents. • Review and approve corrective action plans in support of the audit observations, ensuring alignment with strategic direction of the company. • Assist in driving implementation of the applicable actions. • Travel up to 60% of time. • Support the strategic development of an effective global risk-based audit strategy and programme; collect, collate and incorporate input into audit strategy and plan. • Lead, plan, conduct, document and follow-up of global quality regulatory compliance audits and assessments of GPvP according to the requirements specified in the respective Novartis Quality Module as well as applicable regulations, standards, quality agreements, and guidance documents. • Perform activities with a high degree of independence. • Provide technical guidance, leadership, mentoring and training of other auditors on audit related activities. • Prepare audit reports according to NVS requirements and timelines. • Ensure appropriate escalation to responsible management in case of critical findings and support immediate follow-up measures according to NVS requirements on Management Escalations and other relevant procedures. • Assess the adequacy of responses (CAPA plans) to audit findings in cooperation with Follow-up Responsible Person (FURP) and Quality Responsible Person (QARP). • Identify and communicate quality and regulatory compliance issues to Quality Management through appropriate channels as well as recommend remediation. • Lead compliance investigations and initiatives focused on inspection readiness and quality, process and compliance improvement as requested. • Support Mock Pre-Approval Inspections (PAIs) and Health Authority (HA) inspections as needed.

• Review and audit medical records to ensure accurate coding of diagnoses, procedures, and services using ICD-10, CPT, and HCPCS codes. • Ensure that coding practices comply with federal, state, and payer-specific regulations and guidelines, including HIPAA and CMS standards. • Detect discrepancies and coding errors, provide feedback, and collaborate with coding staff to correct inaccuracies in medical documentation. • Provide training and support to coding staff on best practices, coding updates, and compliance standards. • Prepare detailed audit reports that highlight findings, trends, and areas for improvement. • Work closely with medical billing, compliance, and clinical teams to ensure that coding supports accurate billing and reimbursement processes.