This process works on identifying discrepancies between medical records and billed services for complex and high value claims by identifying Up-coding, Unbundling, Duplication, and Misrepresentation of services.
They approve/deny claims & Identify provider aberrant behavior patterns. The associates prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise, knowledge of CPT/ diagnosis codes, CMC guideline along with referring to client specific guidelines and member policies.
- Medical degree – BHMS/BAMS/BUMS/BPT/MPT/B.Sc Nursing
- Attention to detail & quality-focused
- Good analytical & comprehension skills