MedReview Inc.

Product Manager

• Provide subject matter expertise in outpatient hospital and professional reimbursement methodologies, especially including APC, EAPG, and other grouper-based methodologies.
• Review and interpret client guidelines and policy, provider contract language, and State and Federal regulations to identify audit opportunities.
• Develop, refine, and validate audit concepts and payment integrity rules to identify inappropriate billing and resulting payment errors.
• Collaborate with product, data analytics and technology teams to design and test outpatient claim selection logic.
• Analyze large volumes of claims data to identify coding trends, billing patterns, and emerging opportunities for new audits.
• Interpret and apply CMS and payer guidelines to ensure regulatory compliance and alignment with current coding standards.
• Support product development initiatives by providing clinical and coding insight throughout the product lifecycle.
• Assist with documentation, training materials, and validation testing for new and updated audit concepts.
• Champion training for auditors and coders to ensure consistent application of outpatient audit methodologies.
• Review audit findings for selection accuracy and to ensure alignment with regulatory and payer policies.
• Provide input on operational workflows and documentation standards to improve audit efficiency and quality.
• Monitor and communicate regulatory updates affecting outpatient reimbursement.
• Prepare and present findings, reports and recommendations to internal stakeholders.

Outpatient Coding Product Manager

Medical Director

• Reviewing hospital medical records submitted for DRG Clinical Validation Review to ensure select diagnoses were billed appropriately and are supported in the medical record.
• Producing a concise summary of the clinical course, including diagnostic studies and other relevant data.
• Composing a rationale consistent with guidelines, literature, client policy, and standard of care for any adverse finding.
• Reviewing cases to identify potentially preventable near-term readmission, identify appropriate inpatient Level of Care, and assist with Independent Peer Review, and Utilization Management.
• Developing and updating DRG Clinical Validation Review criteria.
• Participating in quality assurance activities related to clinical review programs.

Medical Director – Physician Reviewer

Auditor

• Analyze and review inpatient claims following the Official Coding and Reporting Guidelines to validate the reported ICD-10-CM/PCS codes to ensure proper DRG assignment for accurate billing.
• Demonstrates the ability to perform a comprehensive initial review as outlined in the standard operating procedures and departmental guides.
• Collaborates with physician reviewers, as needed.
• Ability to prioritize and organize workload and complete tasks independently.
• Required attendance of all departmental team meetings and/or training.
• Work on other duties or tasks, as necessary.
• Report productivity daily utilizing department productivity report.
• Meet/exceed daily productivity expectations.
• Maintains 95% accuracy in claim reviews.
• Required to work a 7.5-hour workday within the company’s core hours.
• Comply with organization policy and procedures.

Outpatient Coding Product Manager

Medical Director – Physician Reviewer

DRG Coding Reviewer/Auditor