Serve as the SME for ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding

Perform DRG validation and retrospective medical claims reviews

Analyze inpatient and outpatient claims for coding accuracy and pricing determinations

Prepare determination letters and written review outcomes

Identify potential fraud, quality concerns, and coding discrepancies

Provide training and mentorship to clinical coding staff

Support cross-functional teams with coding guidance and review findings

Research medical policy, benefits, limitations, and current coding guidelines

Ensure timely completion of reviews in accordance with performance standards

Maintain accurate documentation within medical management and claims systems

Escalate complex cases to the Medical Director when appropriate