Special Investigations Unit Clinical Certified Coder

About the role

MetroPlusHealth is seeking a highly qualified candidate for a Clinical Coder role within our Special Investigations Unit. The Clinical Certified Coder will support the Plan in the detection, prevention and investigation of suspected fraud, waste, and abuse. The position reports to the Director of Special Investigations Unit.

Responsibilities

• Review medical records and healthcare claims to determine the accuracy and compliance of billed codes with appropriate regulations, standards, policies and procedures.
• Conduct audits of high-risk claims and billing patterns to ensure adherence to healthcare regulation and MetroPlusHealth policy and detect potential FWA.
• Collaborate with other SIU team members to evaluate suspected cases of fraudulent activities, such as over-utilization of services, upcoding, and billing for non-medically necessary services.
• Create detailed reports with medical review findings that include research, rationale, sources and corrective action recommendations to the SIU Department. The reports will also validate whether audited claims should be denied, recouped and if other mitigation strategies are required.
• Participate as needed on provider calls to discuss findings and rationale of medical review.
• Present findings to leadership and other stakeholders to facilitate all FWA proceedings.
• Assist in preparing documentation for audits, recoupments, compliance/legal reviews and regulatory inquiries.
• Maintain thorough documentation of investigations, including clinical findings, coding discrepancies and all communication with healthcare providers and investigators.
• Stay updated to changes to coding guidelines, healthcare regulations, and fraud detection methods to ensure compliance and effective investigations.
• Completes special projects and audits as required.

Requirements

• 5 years of experience in healthcare fraud detection, investigation, or auditing
• In depth experience and knowledge of coding regulations including ICD-10, CPT, HCPCS, AMA etc.
• AAPC Coding certification - Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) or Certified Coding Specialist (CCS)
• Bachelor’s degree in Nursing, Medical Billing/Medical Coding, Healthcare or other related fields
• Preferred candidate will have experience in Medicaid, Medicare, and Marketplace/Exchange

Professional Competencies

• Integrity and Trust
• Customer Focus
• Excellent Microsoft Office Suite skills
• Strong communication skills to interact with providers, medical management, legal teams, and compliance departments.
• Strong analytical, research and problem-solving aptitude with attention to detail and accuracy