• Perform clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • Report to the Payment Assurance Senior Manager and support a culture and work environment that promotes and inspires an active, continuous improvement philosophy regarding products and services in line with our company mission. • Audits and analyzes neonatal intensive care unit (NICU) claims according to ICD-10 coding principles and clinical guidelines. • Analysis of claims data to optimize reimbursement by ensuring that the diagnosis codes, procedure codes, and supporting documentation accurately support the service rendered. • Ensure claims analysis complies with ethical coding standards, guidelines, and regulatory requirements. • Responsible for performing clinical reviews of medical records and other documentation to validate issues of claims coding accuracy, medical necessity, and the appropriateness of treatment settings and services delivered. • Utilize Clinical Review Tools and EMR Systems. • Research reimbursement regulations for claim payment compliance to support and validate audit findings. • Assist with the development of claims audit process documentation, including workflow diagrams, policies and procedures, and standard operating procedures. • Detect discrepancies in provider billing and recommend adjustments to ensure proper reimbursement.

• Performs medical claim reviews for claims for medically complex services • Services that require preauthorization/predetermination • Requests for appeal or reconsideration • Referrals for potential fraud and/or abuse • Correct coding for claims/operations • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • Documents medical rationale to justify payment or denial of services and/or supplies • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. • Participates in quality control activities in support of the corporate and team-based objectives • Provides guidance, direction, and input as needed to LPN team members • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback • Assists with special projects and specialty duties/responsibilities as assigned by Management

• Performs medical claim reviews for one or more of the following: claims for medically complex services, services that require preauthorization/predetermination, requests for appeal or reconsideration, referrals for potential fraud and/or abuse, and correct coding for claims/operations • Makes reasonable charge payment determinations based on clinical/medical information and established criteria/protocol sets or clinical guidelines • Determines medical necessity and appropriateness and/or reasonableness and necessity for coverage and reimbursement • Documents medical rationale to justify payment or denial of services and/or supplies • Educates internal/external staff regarding medical reviews, medical terminology, coverage determinations, coding procedures, etc. in accordance with contractor guidelines • Participates in quality control activities in support of the corporate and team-based objectives • Provides guidance, direction, and input as needed to LPN team members • Provides education to non-medical staff through discussions, team meetings, classroom participation and feedback • Assists with special projects and specialty duties/responsibilities as assigned by Management

• Provide operational support to the Medical Review Manager and the Medical Review Staff in managing production related to claims determinations and review • Serve as a critical component in meeting our mission of providing excellent services to our clients. • Ensure an exciting and rewarding opportunity to be at the forefront of activities related to implementing healthcare reform on a national level. • Review and analyze sampled Medicare claims using associated medical records to make payment determinations based on coverage, coding, and utilization of services. • Make medical necessity determinations utilizing clinical review judgment in accordance with the CERT Program policies and contract responsibilities. • Serve as a resource for medical review specialists involving coverage, coding, and medical necessity issues. • Conduct in-depth claims analysis utilizing ICD-9-CM, ICD-10-CM, CPT-4, and HCPCS Level II coding principles. • Conduct medical record audits to determine the medical necessity and/or appropriateness of medical treatment using CMS and other national guidelines.