The Payment Integrity Analyst reviews and audits pre and post-pay claims to ensure compliance with client policies, industry standards, and CMS guidelines. The role involves utilizing clinical judgment to interpret documentation and collaborating with internal teams to complete appeals and audits.
The Director of CERIS Operations provides leadership and strategic oversight for non-clinical business functions to ensure operational excellence and compliance. This role manages cross-functional teams and implements process improvements to support long-term growth and client value.
The Team Lead provides support to the Itemization Review Supervisor and coordinates with internal departments to ensure processing accuracy. They are responsible for analyzing billing data, documenting conclusions, and maintaining quality assurance standards for the team.
The Itemization Review Nurse analyzes medical facility charges on UBIB forms to ensure billing accuracy. They are responsible for documenting conclusions and maintaining compliance with HIPAA regulations.
The Recovery Team Lead manages staff assignments and monitors claims audit data to ensure accurate and timely processing. They also analyze revenue cycle transactions and lead initiatives to improve departmental service delivery and resolve escalations.
The Provider Management Analyst verifies provider information and documentation to audit medical claims for accuracy. They also communicate with leadership regarding issues and ensure the confidentiality of sensitive patient and provider data.
The analyst is responsible for reviewing and monitoring repricing audit data to ensure accuracy, compliance, and efficiency across multiple platforms. They will identify quality issues, implement QA policies, and collaborate with stakeholders to align quality objectives.
Review and analyze provider inquiries and appeals via various communication channels in accordance with regulatory and client guidelines. Ensure all appeals are accurately set up and initiated in a timely manner to support efficient processing.
The Clinical Auditor performs DRG validation reviews of medical records to ensure billing accuracy and compliance with regulatory standards. They also assist the quality control team and medical director with appeals and rebuttals while identifying potential reimbursement savings.
The Certified Coder reverses codes previously coded medical bills to verify coding accuracy and is responsible for making claim-related recommendations and communicating the status of the claim to involved parties. This role involves processing claims based on state rules, determining claim validity using proprietary programs, and adhering to client and carrier guidelines.
The supervisor manages the daily activities of the payment integrity team, focusing on quality assurance and provider appeals, ensuring timely and accurate processing of requests and audits. Responsibilities include assisting the team with complex questions, conducting reviews based on clinical knowledge and payer policy, and managing employee guidance, coaching, and performance appraisals.
