• Support the Managed Service Organization (MSO) by performing detailed medical claims reviews to ensure accuracy, compliance, and appropriate reimbursement across Medicare, Commercial, and Medicaid lines of business. • Focus on validating diagnosis and procedure coding, identifying improper billing or documentation, and supporting medical necessity determinations in alignment with CMS and payer-specific guidelines. • Serve as a key liaison between care management and claims operations to promote coding accuracy and support efficient payment processes within value-based care arrangements. • Review provider medical records to validate the following claim data: Codes billed are accurate, complete, and comply with MSO and payer policies; Codes billed comply with bundling and unbundling guidelines and global period policies; ICD-10 codes are chosen appropriately and to the highest level of specificity; CPT and HCPCS codes accurately report the services rendered including level of E&M code in accordance with AMA, CMS, and state-specific coding standards; Documentation supports billed services under Medicare, Medicaid, and Commercial payer rules. • Identify and report potential coding errors, documentation gaps, or billing inconsistencies that impact reimbursement or compliance. • Collaborate with nurses, medical director, and claims teams to adjudicate/deny claims with coding and/or documentation errors. • Support retrospective and prospective reviews to improve claims accuracy and reduce preventable denials. • Participate in internal audits, education sessions, and process improvement initiatives to enhance coding integrity. • Stay current on updates to CMS regulations, payer billing policies, and industry coding changes. • Protect member and provide confidentiality by adhering to HIPAA and MSO compliance standards.