Fraud & Coding Compliance Specialist

University Health System- San Antonio; San Antonio (TX); On-site; USD 30,000 - 52,000; Full time

Job summary

Community First Health Plans is seeking a Code and Documentation Compliance Specialist-CFHP to join the SIU team. The role focuses on advanced coding audits, data collection, and generating statistical reports to support compliance with federal and state regulations.

The candidate will conduct investigations related to fraud and abuse, review eligibility, claims, and provider contracts, and help educate staff and physicians based on findings from audits.

Qualifications

• Five years of experience with ICD-10-CM/DRG assignment, chart auditing, and CPT4 coding.
• Knowledge of ICD-10 and Microsoft Office products.
• Must have completed a Certified Coding Program or Health Information Management Program to qualify for reduced experience.

Responsibilities

• Audit coding and documentation to ensure compliance with federal and state laws.
• Research eligibility, claims payments, benefits, prior authorization/referrals, and contracts.
• Identify overpayments to providers and assist with anti-fraud initiatives.
• Conduct investigations related to fraud and abuse under SIU supervision.

Skills

ICD-10-CM/DRG assignment

Chart auditing

CPT4 coding

Data reporting

Microsoft Office

Education

High school diploma or equivalent

Certified Coding Program or Health Information Management Program

Tools

Microsoft Office

Job description

Community First Health Plans is seeking a Code and Documentation Compliance Specialist-CFHP to join the SIU team. The role focuses on advanced coding audits, data collection, and generating statistical reports to support compliance with federal and state regulations.

The candidate will conduct investigations related to fraud and abuse, review eligibility, claims, and provider contracts, and help educate staff and physicians based on findings from audits.