Program Integrity Documentation Reviewer III (CPC, RHIT or RHIA required) locations Remote time type Full time job requisition id R12456 Job Summary: The Program Integrity Medical Coding Reviewer III generates comprehensive and concise in-depth reporting and analysis to track performance related to the Pre-Pay and Post-Paid Processes. Essential Functions: - Provide Provider Pre Pay production and progress reports and coordinate with management and team on recommendation for further actions and/or resolutions in order to increase team performance - Recommend process or procedure changes while building strong relationships with cross departmental teams such as Claims, Configuration, Health Partners, and IT on identified internal system gaps - Demonstrate leadership ability, including mentoring Program Integrity Claims Analysts to identify and perform oversight and monitoring of claims decisions based on documentation. - Identify knowledge gaps and provide training opportunities to team members - Coordinate the training of new and existing claims analyst staff to increase recognition of improper coding, documentation, and/or FWA - Identify and assist in correction of organizational workflow and process inefficiencies - Serve as the primary resource for provider pre-pay team - Use concepts and knowledge of CPT, ICD10, HCPCS, DRG, REV coding rules to analyze complex provider claims submissions - Research, comprehend and interpret various state specific Medicaid, federal Medicare, and ACA/Exchange laws, rules and guidelines - Maintain a working knowledge of all state and federal laws, rules, and billing guidelines for various provider specialty types along with documentation requirements - Responsible for making claim payments decisions on a wide variety of claims including highly complicated scenarios using medical coding guidelines and policies - Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business - Responds to claim questions and concerns - Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed - Possess a general knowledge and understanding of CareSource claim payment edits - Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims - Build strong working relationships within all teams of Program Integrity - Work under limited supervision with considerable latitude for initiative and independent judgement - Perform any other job related instructions as requested Education and Experience: - Associate’s degree or equivalent years of relevant work experience is required - Minimum of five (5) years of medical billing and coding experience to include minimum of three (3) years of SIU/FWA medical billing and coding experience is required - Prior experience with claim pre-payment, medical claim and documentation auditing required - Medicaid/Medicare experience is required - Minimum of three (3) years of experience in Facets is preferred - Experience with reimbursement methodology (APC, DRG, OPPS) is required - Inpatient coding experience is preferred - Leadership experience is preferred Competencies, Knowledge and Skills: - Knowledge of diagnosis codes and CPT coding guidelines; medical terminology; anatomy and physiology; and Medicaid/Medicare reimbursement guidelines - Thorough understanding of medical claim configuration - Clinical or medical coding background with a firm understanding of claims payment - Proficient in Microsoft Office Suite - Firm understanding of basic medical billing process - Excellent written and verbal communication skills - Ability to work independently and within a team environment - Effective problem solving skills with attention to detail - Knowledge of Medicaid/Medicare and familiarity of healthcare industry - Effective listening and critical thinking skills - Ability to develop, prioritize and accomplish goals - Strong interpersonal skills and high level of professionalism Licensure and Certification: - Certified Medical Coder (CPC, RHIT or RHIA) is required at time of hire Working Conditions: - General office environment; may be required to sit or stand for extended periods of time Compensation Range: $62,700.00 - $100,400.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package. Compensation Type (hourly/salary): Salary Organization Level Competencies - Fostering a Collaborative Workplace Culture - Cultivate Partnerships - Develop Self and Others - Drive Execution - Influence Others - Pursue Personal Excellence - Understand the Business This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds. #LI-SD1

• Establish and enforce the "Gold Standard" for project controls • Provide rigorous QA/QC over schedules, cost forecasting, and risk reporting • Identify skill gaps, provide training, and foster high-performance culture • Proactively identify delivery bottlenecks and architect recovery plans • Design and execute an escalation management strategy for risk mitigation • Lead the seamless integration of new procedures and PMO tools into the workflow • Constantly challenge the status quo to refine methodologies

• Lead end-to-end planning and execution of startup activities • Solve complex problems that pose risk to project delivery • Lead change initiatives by developing clear communication plans • Partner with Engineering, Facilities, Supply Chain, HR, Regulatory, Sales • Influence senior leaders and peers to drive decision-making • Establish and implement best practices for safety, quality, productivity • Build and lead high-performing startup teams • Identify and mitigate risk related to startup timelines • Define KPIs and success metrics for startup milestones • Leverage data to derive insights and make informed decisions

Experience - 8 to 17 years Location - Chennai Notice Period - 45 days About Us “Capco, a Wipro company, is a global technology and management consulting firm. Awarded with Consultancy of the year in the British Bank Award and has been ranked Top 100 Best Companies for Women in India 2022 by Avtar & Seramount. With our presence across 32 cities across globe, we support 100+ clients across banking, financial and Energy sectors. We are recognized for our deep transformation execution and delivery. WHY JOIN CAPCO? You will work on engaging projects with the largest international and local banks, insurance companies, payment service providers and other key players in the industry. The projects that will transform the financial services industry. MAKE AN IMPACT Innovative thinking, delivery excellence and thought leadership to help our clients transform their business. Together with our clients and industry partners, we deliver disruptive work that is changing energy and financial services. #BEYOURSELFATWORK Capco has a tolerant, open culture that values diversity, inclusivity, and creativity. CAREER ADVANCEMENT With no forced hierarchy at Capco, everyone has the opportunity to grow as we grow, taking their career into their own hands. DIVERSITY & INCLUSION We believe that diversity of people and perspective gives us a competitive advantage. MAKE AN IMPACT Role Description Responsibilities - Masterplan • Support the Head of T&O Program Masterplan & Schedule Management on resolving program conflicts and proactive management of cross-program dependencies to mitigate delivery bottlenecks and optimize sequencing and throughput. This includes: • Facilitate daily/ weekly forums, including minutes of meetings (MoM) documentation, to manage cross-program dependencies, facilitate communication, and resolve conflicts in a timely manner • Create and maintain comprehensive artefacts (e.g., portfolio masterplan, concentration risks analysis and impact assessment) monthly for actionable insights to T&O Management Teams, Investment Committees and relevant business units • Support bank-wide outreach initiatives and coordinate with relevant stakeholders to resolve scheduling conflict or gather/ validate data for trend analysis • Conduct scenario analysis (on a as-needed basis) to identify potential risks, outline implications and recommend strategic actions • Explore and implement automation solutions for compiling the portfolio masterplan • Develop and maintain strong relationships with key stakeholders to ensure seamless communication and collaboration • Provide ad-hoc support to T&O Management Teams or strategic programs in responding to regulators Responsibilities – Process Mapping • Support the Head of T&O Program Process Design & Mapping on documenting, standardizing, and optimizing end-to-end processes across transformation programmes. The role focuses on ensuring process clarity, ownership alignment, and efficiency within and between key delivery workstreams. This includes: • Facilitate process walkthroughs and workshops with business, operations, and technology teams to capture current (“as-is”) and target (“to-be”) process states. • Develop and maintain detailed process maps, swim lanes, and control points in accordance with Group standards. • Identify process gaps, redundancies, and control weaknesses, and propose design improvements or automation opportunities. • Collaborate with programme and QA teams to ensure process maps align with approved solution designs, business requirements, and operating models. • Maintain a central process inventory and ensure version control for process artefacts and related documentation. • Coordinate with Risk, Controls, and Audit teams to validate that mapped processes meet compliance and regulatory requirements. • Provide insights and recommendations to T&O Management and Governance Committees to support decision-making and continuous improvement. • Deliver ad-hoc process mapping and analysis support to major transformation programmes or regulatory remediation initiatives. Responsibilities – Deep Dives (Quality Assurance) • Support the T&O QA Lead in conducting structured deep-dive reviews on priority programmes to assess delivery readiness, design quality, and adherence to governance standards. This includes: • Plan and execute QA deep dives across programme workstreams and delivery phases, focusing on design, architecture, and control effectiveness. • Review key artefacts (e.g. BRDs, Solution Intents, Release Plans, RAIDs) to validate completeness, traceability, and evidence of stakeholder endorsement. • Identify control gaps, design weaknesses, and governance deviations; document findings and recommended actions. • Engage directly with Programme Leads, Architects, and PMOs to confirm facts, validate progress, and track remediation. • Prepare QA summary reports highlighting key risks, maturity assessment, and evidence-based assurance ratings. • Support QA input into SteerCo packs, PgSC updates, and audit responses. • Maintain central QA evidence logs, trackers, and lessons learned for future assessments. Responsibilities – Resourcing • Responsible for assessing the bank’s current resourcing landscape, identifying gaps and inefficiencies, and designing a Target Operating Model (TOM) to enhance resourcing estimation, man-day forecasting, and cost management. The role will also focus on streamlining processes related to hiring requests and workforce planning. This includes: • Analyse large and complex datasets to assess the current resourcing state, identify issues, and develop actionable insights. • Provide ad hoc analytical support on various resourcing topics as needed to inform decisions and drive continuous improvement. • Work closely with stakeholders across functions to understand current pain points, clarify requirements, and align on improvement opportunities. • Design and implement process enhancements to improve accuracy, efficiency, and transparency in resourcing and forecasting. • Navigate ambiguity effectively and make data-driven recommendations to support decision-making in a dynamic environment. Key Requirements: • Communication & stakeholder management: Strong verbal and written communication skills to effectively interact with tea members and stakeholders; ability to manage multiple stakeholder groups to facilitate alignment in complex environments • Problem-solving & analysis: Ability to identify issues/ root causes and contributing to the development of effective solutions; analyse data to support decision-making • Adaptability: Flexibility to adapt to fast-changing environments and requirements, and ability to digest new concepts quickly • Proactivity: Taking initiative to identify potential risks and issues early, and support the implementation of mitigation strategies • Visualization & attention to detail: Ability to create clear and engaging slides/ visuals tailored for different types of audiences, ensuring accuracy and effective communication of key messages • Project management: Basic understanding of project management principles, including prioritization, resource allocation and schedule management Preferred Skillsets: • MS Office proficiency: Skilled in Excel, PowerPoint, and Word; experience in working with large data sets • Tool knowledge: Familiarity with Clarity, Tableau and/or Azure DevOps (ADO) is preferred • Tech & Ops Understanding: Basic knowledge of technology and operations concepts (e.g., testing cycles, operational workflows etc.) • Project Management skills If you are keen to join us, you will be part of an organization that values your contributions, recognizes your potential, and provides ample opportunities for growth. For more information, visit www.capco.com. Follow us on Twitter, Facebook, LinkedIn, and YouTube.