Role Description The Physician ED Claims Reviewer will conduct clinical reviews of claims and UM authorization requests for clinical necessity. - Physician with an active US license - Experience in medical coding (CPT/HCPCS) - Minimum of 3-5 years of recent clinical experience in emergency department medicine - Experience in internal medicine will be considered - Experience in managed care and clinical UM case reviews - Knowledge of claims and medical coding (CPT/HCPCS codes) - Proficient in working with various systems and applications Qualifications - Experience/knowledge in utilization management is a plus - Ability to work independently in a fast-paced environment Requirements - This is a remote position

• Responsible for supporting and assisting all cardiology administrative and clinical utilization management and quality improvement functions • Act as a clinical liaison to providers, clients, and patients • Maintain and operate Guideline Directed Medial Therapy • Communicate clinical information needs to ordering providers • Prep cases for P2P discussions • Coordinate with UM staff for communication of clinical decisions • Complete UM projects and participate in site visit reviews • Serve as subject matter expert in assigned meetings

• Perform medical claim reviews for claims requiring preauthorization or appeals • Determine medical necessity and appropriateness for coverage and reimbursement • Document medical rationale for payment or denial of services • Educate staff on medical reviews, coverage determinations, and coding procedures • Participate in quality control activities

• Manages and supports quality and performance improvement by assisting staff to implement strategies that identify, prioritize, measure, and improve key clinical processes and outcomes • Reviews patient records to determine the complete, accurate, and timely documentation of all conditions that support home health/hospice care and treatment of the patient • Reviews and interprets patient records and compares against criteria to determine medical necessity and appropriateness of care • Consults with providers, management, and operations to ensure consistency within the application of clinical criteria • Utilizes clinical expertise for the review of medical records against appropriate criteria in conjunction with contract requirements • Maintains current knowledge of clinical indicators and compliance requirements • Manages tools to collect outcome data and provides regular feedback to individuals, managers, and leaders • Provides concurrent medical record review to assess documentation compliance • Facilitates recommended interventions • Reviews deficiencies in documentation with involved staff and facilitates corrective action • Participates in the ongoing development and implementation of an established performance improvement plan • Reviews orders for data entry, completeness, and appropriateness for admission to home health/hospice services • Promotes, obtains, and reviews appropriate documentation for any home health/hospice specific quality data