- Investigate potential payment inaccuracies using Medicare Advantage adjudication and reimbursement knowledge.
- Review claims populations identified through SQL analysis and distinguish payment discrepancies from valid exceptions, data issues, and correctly adjudicated claims.
- Research CMS/NCCI and other coding guidance, provider contract terms, benefit documents, and internal payment policies and configuration requirements.
- Analyze claim and line detail, payment components, adjustments, reversals, and related claim history to assess expected payment outcomes.
- Independently run SQL queries and make targeted changes to dates, filters, and claim selections.
- Document applicable sources, validation steps, exclusions, supported payment impact, and unresolved questions.
- Use approved AI tools to support research, query interpretation, and documentation while verifying outputs.
- Review audit-tool outputs, identify false positives, and refine rules to improve precision.
- Prepare findings for review and support recovery evaluation, operational resolution, and Compliance/Legal review as needed.
- Contribute to recurring audits and recommend improvements to investigation and testing processes.
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