• Review and analyze Medicare claims sampled by the Department of Justice, using associated medical records, to make payment determinations based on coverage, coding and utilization of services and practice guidelines. • Conducts medical record claims review to determine correct coding, utilizing ICD-9-CM, ICD-10, CPT-4, and HCPCS Level II coding principles. • Review medical documentation for medical necessity utilizing clinical knowledge and CMS policies and guidelines, as well as other state and board regulations. • Conducts in-depth claims analysis of suspected over-utilizers who are suspect of fraudulent billing practices. • Completes summary report upon completion of the records review, summarizing claim determinations, clinical observations and other information requested by the DOJ. • Reviews and completes the required number of claims reviews in accordance to pre-established production standards for the project. • Produces and submits required reports according to established content and timeframes. • Communicates internally with all levels of the group. • Participates in Quality Assurance (QA) and IRR monitoring as requested. • Complies with departmental policies and procedures. • Complies with Medicare and DOJ guidelines and CMS directives, policies and regulations pertaining to integrity, fraud, overpayments, and the handling and disclosure of information. • Attends departmental and required education and training programs. • Reviews information contained in Standard Claims Processing System to determine provider billing patterns and detect fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies. • Utilizes the Medicare/Medicaid guidelines for coverage determinations. • Performs in-depth research and investigation utilizing the Internet and other tools, including data analysis tools. • Maintains chain of custody on all documents, follows all confidentiality and security guidelines.