Perform complex medical record and claim reviews for Medicare Part A and Part B services to ensure compliance with coverage policies and payment rules. Evaluate AI-assisted processes for translating policy documents into structured rules and detecting potential indicators of fraud, waste, and abuse.
Review medical records for intake eligibility, abstract diagnoses, and validate documentation against ICD-10-CM, CMS-HCC, and RADV requirements using approved tools and workflows. Record determinations accurately, meet productivity and quality standards, escalate complex cases, protect sensitive data, and contribute workflow improvement insights.
The analyst will integrate healthcare billing and payment datasets to construct summaries for monitoring and evaluation. They will also contribute statistical expertise to research questions regarding federal healthcare policies and collaborate with a multidisciplinary team.
