• Responsible for independently conducting comprehensive reviews of MS-DRG and APR-DRG coding and clinical documentation to ensure the accuracy of DRG assignment and reimbursement. • Requires advanced expertise in ICD-10-CM/PCS coding and the ability to exercise discretion and professional judgment in assessing complex clinical information, validating diagnosis code assignments, and identifying discrepancies such as coding errors or upcoding. • Operates with significant autonomy in supporting DRG validation reviews and appeals, interpreting regulatory requirements, and making authoritative decisions to ensure compliance with all applicable laws, payer contracts, and organizational policies. • Independently conducts comprehensive MS-DRG and APR-DRG coding and clinical validation reviews, exercising professional judgment to verify ICD-10-CM/PCS assignments, validate clinical diagnoses, identify discrepancies, and apply inpatient reimbursement rules without direct supervision. • Collaborates with the Medical Director on complex cases, providing expert recommendations and influencing review outcomes to ensure clinical accuracy and compliance. • Leads the evaluation of complex cases and proactively identifies opportunities to develop medical policy in the absence of established guidelines, demonstrating discretion and authority in decision-making. • Applies advanced knowledge of coding guidelines and clinical policies throughout the review process, making autonomous determinations regarding coding accuracy and regulatory compliance. • Prepares clear, concise, and well-supported audit findings, referencing authoritative sources such as AHA Coding Clinic and ICD-10 guidelines, approved Centene policies, and adopted clinical guidelines, ensuring recommendations reflect professional expertise. • Evaluates claims and medical records for compliance with state and federal regulations, payer contracts, and company policies, exercising independent judgment in interpreting requirements and resolving ambiguities. • Consistently meets or exceeds established quality and productivity standards while managing priorities and workflow autonomously. • Contributes to strategic initiatives by assisting in the development of audit concepts, identifying new audit opportunities, and selecting claims for review, demonstrating leadership in shaping audit methodologies. • Performs other duties as assigned. Complies with all policies and standards.

• Provide a holistic evaluation for domestic and international applications for undergraduate admission. • Review all application materials and make an admissions recommendation based on extensive training. • Attend and participate in monthly trainings and individual coaching sessions, and other meetings as needed during normal university business hours. • Enter recommendations for completed reviews into the review site on a weekly basis. • Ensure confidentiality and security of the admissions process, files, and university materials.

• Responsible for utilization review calls within BHS, including precertification, continued stay review, discharge reviews, and retrospective reviews and appeals. • Works closely with business office staff, clinical staff, and physicians to advocate for BHS patients with insurance and managed care companies. • Communicates insurance input to physicians and clinical staff making discharge plans for patients. • Assists clinical staff with assessments as needed, primarily as in a back-up capacity. • Communicates daily with Utilization Review Coordinator, and as needed with business office and admissions staff to understand admissions and transfers, patient benefit information, and precertification status. • Understands health care benefit plan provisions and managed care contracting. • Communicates and coordinates efforts at appealing unfavorable utilization review decisions.

• Performs clinical chart reviews and audits to ensure accuracy and compliance with HEDIS measures. • Develops reports to identify HEDIS care gaps and trends and works closely with providers to ensure the necessary services are provided and documented according to HEDIS requirements. • Assists in the coordination of outreach efforts to request, collect, and secure clinical documentation from individual providers or provider groups as indicated by individual HEDIS measure specifications. • Collaborates with health plan departments to identify HEDIS data sources and develop systems to capture this data in accordance with HEDIS technical specifications, such as supplemental databases. • Collaborates with data analysts and quality teams to support performance improvement. • Documents findings and recommends strategies to improve HEDIS measure performance. • Applies clinical expertise to identify and validate data discrepancies. • Educates non-clinical staff on HEDIS requirements and clinical relevance of data. • Corresponds with members and clinical providers to effectively coordinate care, obtain medical records, and ensure patients receive preventive and chronic disease management services.