The auditor is responsible for conducting pre-claim and post-claim coding audits to ensure accuracy, completeness, and regulatory compliance. They will also provide coding education to staff and providers while maintaining high quality and productivity standards.
The Provider Relations Representative is responsible for contracting and credentialing providers to ensure CMS network adequacy. They also educate providers on health plan functions and maintain ongoing relationships to support network coverage.
The Utilization Review Nurse assesses the medical necessity and quality of healthcare services through pre-service, concurrent, and retrospective reviews. They provide clinical support to ensure members receive appropriate medical services in compliance with regulatory guidelines.
