EPIC cci edits and billing splits.

Revenue Integrity CDM analyst

• Reviews all client contracts (3rd Party, Direct, MSP and Associate Vendor) for all divisions under the direction of the Regional Clinical Leader to ensure consistent language with AMN standards• Organizes and prioritizes new contracts, renewals, addendums and amendments to ensure timely processing and completion of assigned activities• Ensure consistent application of standardized requirements across clients, the Client Contracts Specialist is responsible for preparing and updating an E-book and supporting reports used by Clinical• Collaborates with Compliance Auditor to interpret new regulatory and/or accreditation requirements that may impact the industry and present proposal to management to determine appropriate action to be taken• Provides support to assigned region and Clinical Leadership as needed for ad hoc events or special projects (Strike events, EMR projects, State audits, etc.)• Produces metrics for compliance projects and achieves productivity targets as designed by Clinical Leadership• Builds candidate qualification and credentialing requirements in all appropriate systems and in a timely manner• Promotes Clinical Management Organization as industry experts and demonstrates service excellence to ensure internal and external customer satisfaction• Reads, analyzes, and interprets routine client contracts efficiently and effectively

• Resolves CCI billing edits and claim edits within accounts.• Maintain the integrity of facility Charge Description Master (CDM) and Revenue Integrity Systems Program.• Correct OCE claim edits based on compliance recommendations • Liaison between coding department to ensure correct coding on all procedures• Manage Rev Builder integrity program to update and correct claims that failed edits• Performs random chart audits on NICU, Telemetry, and hospital transfers as needed• Performs OP Coding on all hospital claims and stand-alone clinics in the UT System network• Work in conjunction with Chargemaster to update codes and request updated EAP• Performs table audits on PM&R clinics• Perform financial analytics for hospital accounts via Power BI.

Quality Assurance SR.

I process the rates for hospitals in the Oklahoma, Louisiana Texas region to ensure proper paying of claims.

• Identifies and Enters Claims, audits standard reports and identifies over and under payments of claims.• Process claims including: quality assurance; auditing paid claims; determining whether an overpayment exists; duplicate payments; identifying incorrect contract or contract rates; Data Mining; Medical Chart Review; Medical Necessity; Claims Adjudication• Prepare Response to Client and Supplier Disputes. Respond to client/Supplier disputes for claims written. Provide verification of claims validation and confirmation, in a concise written manner.• Recommend New Concepts. Leverages knowledge of client, contract terms and complex claim types. Works towards developing and implementing new ideas approaches and technological improvements that will support and enhance audit production, communication and client satisfaction.• Investigates fraud waste & abuse per CMS and contract guidelines within Medicare, Medicaid system.• Provides investigative support to the Special Investigations Unit (SIU) related to coding and billing issues and identifies potential overpayments and suspected health care fraud and abuse.• Plans out business analysis efforts, including stakeholder analysis, communication planning, and elicitation techniques.• Ensure the project teams have clear, consistent, and testable requirements.• Support traceability efforts from high-level business needs through functional validation• Collaborate with stakeholders, team members and analysts regarding requirements development and translation into software specifications.• Plans out business analysis efforts, including stakeholder analysis, communication planning, and elicitation techniques.

• Investigated the Managed Care Member Appeals in accordance with established policies.• Prepared case summaries within established timeframes and documented related activities in the respective database and/or system for committee review by collecting pertinent data that included claims, screens, denial letters, and other clinical information from Patient Care Management.• Requested medical records from practitioners when needed to ensure accurate appeal processing.• Reviewed completed cases and forwarded files to the committee team.

• Oversaw the claims adjudication process to assure that the examiners are following all CMS rules and regulations in conjunction with the insurance company guidelines• Investigated and pursued recoveries and payables on subrogation claims.• Examined, assessed, and documented business operations and procedures to ensure data integrity, data security and process optimization