Data Mining Auditor

Codoxo is the premier provider of artificial intelligence-driven solutions and services that help healthcare companies and agencies proactively detect and reduce risks from fraud, waste, and abuse, ensuring payment integrity. Our software-as-a-service applications are built on our proven Forensic AI Engine, using patented AI-based technology to identify problems and suspicious behavior faster and earlier than traditional techniques.

About the role

The Data Mining Auditor performs medical claim audits to identify overpaid claims by reviewing billing and coding policies, provider contract language, and State and Federal regulations. This includes verifying claims data in customer claims processing systems and reviewing clinical and claims documents to make final determinations. Responsibilities may also include assisting with the development of audit specifications and client deliverables.

Responsibilities

• Perform medical claim audits by reviewing customer claims data and charges, and/or medical records, to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines, customer requirements, and guidelines.
• Draft clear, defensible audit rationales and findings documentation suitable for client review, provider outreach, and downstream recovery or action workflows.
• Collaborate with internal analytics and AI teams to translate clinical, coding, and regulatory requirements into audit concepts, models, and deterministic review logic.
• Maintain excellent quality, accuracy, and high productivity levels.
• Keep current on medical coding guidelines.
• Demonstrate efficient use of relevant software tools.
• Participate in departmental meetings, contribute to business development initiatives, and office functions.
• Prioritize assignments and responsibilities to meet goals and deadlines.

Requirements

• Active coding certification from either AAPC or AHIMA is required.
• SQL or Python experience is highly desirable but not required.
• 4+ years of work experience with a focus on healthcare provider billing and coding audits.
• Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements.
• Knowledge of various reimbursement methodologies, including MS-DRG, APR-DRG, OPPS, per diems, case rates, and RVU calculations.
• Knowledge of Medicare, Medicaid, and Commercial reimbursement methodologies.
• Knowledge of payer claims processing systems is desirable.
• Comprehensive knowledge of industry-standard rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation (e.g., NCCI edits for PTP and MUE, global services, multiple procedure reductions, and COB).
• Proficient user in Microsoft Office Suite. Familiarity with JIRA, SharePoint, and AWS is also desirable.
• Excellent time management, organizational skills, and ability to prioritize work and meet deadlines.
• Exceptional verbal and written communication skills.
• Desire to work within a team environment.

Physical Requirements

Work is performed in an office environment (either in-office or work-from-home) and requires the ability to work on a computer, operate standard office equipment, and work at a desk.

Benefits

• Health, Dental, and Vision insurance with 100% employee premium coverage (starts Day 1).
• Unlimited PTO.
• Annual Professional Development stipend.
• Annual home office stipend.
• 401K Match (after 90 days).

Codoxo is not able to offer sponsorship or accommodate candidates currently being sponsored now or in the future.