Reviews claims daily based on medical necessity, coverage guidelines, coding & payment standard and applicable regulatory and compliance requirements. […]
Reviews services for appropriateness of charges and ensures payments are consistent with authorization information during claims processing.
Reviews and interprets medical records to determine appropriateness of care and its level, identifies any excessive & unchartered charges, non-covered or excluded services, services exceeding benefit limitation and appropriate application of benefit coverage. […]
2.1 Analyzes, processes, researches, adjusts...