Clinical Case Reviews -75% Perform clinical review of professional (or facility) claims vs. medical records to determine if the claim is supported or unsupported Maintain standards for productivity and accuracy.  Standards are defined by the department Provide clear and concise clinical logic to the providers when necessary Examine, assess, and document business operations and procedures to ensure data integrity, data security and process optimization Investigate, recover, and resolve all types of claims as well as recovery and resolution for health plans, commercial customers, and government entities Investigate and pursue recoveries Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance Use pertinent data and facts to identify and solve a range of problems within area of expertise Other internal customer correspondence and team needs - 15% Attend and provide feedback during monthly meetings with assigned internal customer department Provide continuous feedback on how to improve the department relationships with internal team members and departments Continuing education - 10% Keep up required Coding Certificate and/or Nursing Licensure Complete compliance hours as required by the department