- Audit claims for medically appropriate services in skilled nursing facility settings applying medical review guidelines and policies.
- Document all findings referencing appropriate policies and rules.
- Generate letters articulating audit findings.
- Support audit findings during the appeals process if requested.
- Work collaboratively with the audit team to identify vulnerabilities and cases subject to potential abuse.
- Partner with clients and colleagues to improve medical policies, provider education, and system edits.
- Participate in establishing edit parameters, new issue packets, and development of Medical Review Guidelines.
- Assist with QA functions and training team members.
- Interface with and support the Medical Director and cross train in all clinical areas.
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