|Required Experience:||1 to 2 years
Perform retrospective and prepayment reviews of medical records to identify potential abuse and fraud and inappropriate billing practices;
Investigate, analyze, and identify provider billing patterns to recommend payment based on medical records, claim history, billing codes, regulatory and state guidelines, and policies;
Prepare summary of findings and recommend next steps for providers; Identify preventative measures and recommend changes to internal policies and procedures and/or provider practices to prevent future fraudulent and erroneous practices; Consult investigators to identify abuse and fraud by utilizing clinical and coding expertise to analyze patterns in billing activities;
Audit medical records to identify inappropriate billing practices and recommend next steps through extensive review of claims data, medical records, corporate policy, state/federal policy, and practice standards.
Experience: Associate’s degree in a related field or equivalent experience. Coding Certification and 2+ years of medical coding experience; or RN, LPC, LCSW, LMHC, PT, OT or ST license and 2+ years of related clinical experience in the field of obtained license. Experience in provider education preferred.