The Director leads the strategic development and operational oversight of DRG clinical validation and audit initiatives to ensure payment integrity. They manage teams of auditors while collaborating across departments to drive quality outcomes, regulatory compliance, and business growth.
The supervisor will lead a remote team by managing file assignments, monitoring nurse queues, and ensuring accurate reporting and data analytics. They are responsible for maintaining departmental policies, handling client appeals, and fostering a positive, professional work environment.
The Closing Analyst is responsible for closing client files and applying results into Scheck and CareMC systems to meet production standards. They must ensure all documentation is attached, follow departmental QC protocols, and maintain HIPAA compliance.
The VP of Strategic Business Development will lead efforts to strengthen client relationships and serve as the primary point of contact for business development and retention. This role drives strategic alignment across stakeholders and supports the sales team as a subject matter expert to foster growth.
The Clinical Review Supervisor oversees daily activities of DRG Clinical Auditors and ensures the integrity of diagnosis and procedure code verification. They are responsible for maintaining accuracy rates, meeting quotas, and providing clinical support for medical review determinations.
The Clinical Auditor performs DRG validation reviews of medical records to ensure billing accuracy and regulatory compliance. They also assist the quality control team and medical director with appeals and rebuttals while identifying potential reimbursement savings.
The Director, CERIS Audit provides leadership and strategic direction for all clinical and audit review operations to ensure organizational goals and compliance standards are met. This role drives operational excellence, process standardization, and continuous improvement across all review functions while mentoring team members.
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 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 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.
