• Audit third-party vendor coding and CDI outputs to ensure accuracy, compliance, and adherence to contracted performance standards • Audit internal CDI Specialist I and II work, including chart reviews, queries, and reconciliation activities • Identify coding inaccuracies, unsupported diagnoses, missed HCC opportunities, and documentation gaps • Deliver audit findings, trend analysis, and corrective action recommendations to CDI leadership and vendor partners • Track and report audit performance metrics to support continuous quality improvement initiatives. • Review completed encounters in the post-visit, pre-billing window to validate documentation completeness and coding accuracy • Review and audit Pre-visit plan coding and CDI • Evaluate alignment between medical record documentation and draft claims, ensuring proper HCC capture • Assess each diagnosis for appropriate ICD-10-CM specificity and MEAT criteria compliance • Prioritize high-impact conditions and risk-adjustable diagnoses for intervention and resolution • Ensure compliant query practices aligned with AHIMA and ACDIS standards • Review query quality, provider responses, and documentation updates to confirm clinical support for diagnoses • Validate final alignment between documentation and submitted claims, resolving discrepancies in partnership with coding and billing teams • Translate audit findings into targeted provider and team education on documentation, coding specificity, and risk adjustment compliance • Partner with CDI, coding, and leadership teams to improve workflows, policies, and audit readiness • Serve as a subject matter expert and resource on risk adjustment, CDI best practices, and audit standards • Support the evolution of CDI and audit processes as automation, EMR integrations, and vendor models mature • Identify opportunities to expand audit scope (e.g., documentation patterns, provider performance trends, process inefficiencies) • Contribute to the development of scalable audit frameworks and quality assurance methodologies • Deliver real-time and aggregate coding and documentation feedback to providers and their clinical support teams • Design and facilitate education sessions on ICD-10-CM specificity, chronic condition documentation, HCC coding, and risk adjustment compliance both virtually and, on occasion, in person • Perform other related responsibilities as assigned

• Perform comprehensive charge audits for inpatient and outpatient services. • Review itemized billing statements against medical records to verify accuracy and completeness. • Identify and document: • Missing charges • Duplicate charges • Unsupported or non-compliant charges • Validate charges based on clinical documentation, coding rules, and billing guidelines. • Ensure all billing aligns with: • CMS and payer requirements • National healthcare billing audit guidelines • Organizational compliance standards • Submit clear, actionable audit findings to revenue cycle teams for correction and rebilling. • Analyze audit findings to determine root causes and patterns. • Maintain accurate audit documentation that is clear, traceable, and defensible. • Track audit outcomes and financial impact. • Assist in developing recommendations to improve charge capture accuracy and billing processes. • Partner with: • Coding and billing teams • Clinical departments • Revenue cycle leadership • Provide guidance on: • Documentation requirements • Charge capture practices • Billing compliance standards • Support education efforts to prevent recurring audit issues.

• Prospective auditing of exams, procedures, medications, etc.; • Perform preliminary review of medium- and high-complexity authorization forms, issuing a favorable or unfavorable opinion according to scope of competence; • Route authorization forms as needed to the appropriate specialty; • Communicate in writing to the person responsible your observations, recommendations, and conclusions from the preliminary audit.

• Retrospective Medical Claims Audit: Perform technical analysis and auditing of medical-hospital accounts, ensuring compliance between the care provided, billed items, medical protocols and contracted agreements. • Regulatory Management and ANS: Prepare medical opinions and technical responses to Preliminary Intermediation Notifications (NIP) and correspondence directed to the National Supplementary Health Agency (ANS). • Defenses and Appeals: Prepare technical responses and defenses to Notices of Infraction addressed to the ANS, working in coordination with the legal and regulatory departments. • Continuous Improvement: Identify clinical/operational deviations and propose corrective measures to ensure faithful compliance with established standards for the provision of medical care in the supplementary health sector.