• Reviews medical record documentation to verify clinical indicators and coding issues as related to DRG Validation Audits, Emergency Department Downgrade Audits, Inpatient Level of Care Audits, and Charge Outlier Audits, etc. • Creates detailed appeal letters for denials from payer to support payment of patient claims • Manages Inventory and Follow up on accounts as appropriate • Reviews InterQual/Milliman, coding guidelines and/or payer medical policies related to denied procedures or services and includes criteria in appeals letter as appropriate • Provides feedback to supervisor regarding issues identified for ongoing training to peers and non-clinical staff members • Identifies root causes and trends to share with clients and staff • Works with peers in collaboration of clinical writing situations

• Conduct independent, evidence-based file reviews. • Review patient records and related documentation in alignment with clinical guidelines. • Provide objective, high-quality reports within turnaround timelines. • Maintain compliance with URAC, HIPAA, and internal quality standards.

• Conduct comprehensive and objective medical chart reviews with honesty and integrity. • Produce determinations that are clear, concise, and well-supported by evidence. • Follow MMRO’s review templates, ensuring all required elements are complete and accurate. • Communicate findings in a professional manner using appropriate language and grammar. • Complete assigned reviews within the specified deadlines. • Respond promptly to communications from MMRO staff. • Review and comply with corporate training materials and review standards. • Be receptive to constructive feedback from MMRO’s Medical Director, Associate Medical Director, and Clinical Staff. • Contribute ideas for process improvement and quality enhancement.

• Primary review of all premium audits (WC, GL, Garage, etc). • Audit types include: Phone, Mail, Physical, Remote Physical, Virtual • Independently determine if each audit adequately addresses the Afirm QC requirements, standard manual rules, state-specific rules, and client-specific requirements. • Validate time charges with audit detail and/or explanations. • Manage inventory of audits to review. • Meet production requirements and expectations as provided. • Other duties as assigned.