Healthcare Coding Expert (certified professional coder)

General Dynamics Information Technology, Inc.; United States; On-site; USD 90,000 - 130,000; Full time

Job summary

General Dynamics Information Technology, Inc. is seeking a Healthcare Coding Expert to support CMS, focusing on identifying fraud, waste and abuse referrals and leading analytic efforts within HFPP.

The role requires deep expertise in medical coding (ICD-10, CPT, HCPCS), program integrity experience and strong communication skills, with a track record of working on complex data projects and cross-functional collaboration.

Qualifications

• Bachelor's degree or equivalent year of work experience
• 8+ years' experience in healthcare claims analysis
• Certified Professional Coder (CPC) or CCS designation
• Expertise in ICD-10, CPT, HCPCS and medical terminology
• Experience with program integrity, fraud, waste and abuse
• Strong knowledge of insurance regulations and reimbursement methodologies
• Excellent written and oral communication skills
• Proficient in Microsoft Office
• Experience with Tableau, Jira and Confluence; HIPAA knowledge

Responsibilities

• Perform analytical tasks supporting HFPP program and generate referrals and leads
• Collaborate on HFPP analytic reports
• Drive outcome metrics for fraud, waste, and abuse referrals
• Support business development by analyzing health claims data and identifying opportunities
• Review and analyze medical claims for accuracy and compliance
• Identify fraud schemes and conduct policy research
• Participate in QA to ensure regulatory and policy adherence
• Respond to analytic output questions from stakeholders
• Mentor and guide junior team members

Skills

Healthcare coding

Fraud analytics

Communication

MS Office

HIPAA knowledge

Problem solving

Leadership

Detail oriented

Education

Bachelor's degree or equivalent

Tools

Tableau

Amazon WorkSpaces

Jira

Confluence

Job description

GDIT's Federal Health Division is hiring a Healthcare Coding Expert to support the Centers for Medicare and Medicaid (CMS), you will be trusted to identify trends in the data and create leads and referrals for the Healthcare Fraud Prevention Partnership (HFPP) members (Partner) and the Trusted Third Party (TTP).

You will be part of a 50-person team supporting the TTP which was established in 2012 to reduce fraud, waste and abuse in healthcare data.

Work visa sponsorship will not be considered for this position

WHAT YOU'LL BE DOING:

• Performs analytical tasks in support of HFPP program, including identifying fraud, waste, and abuse referrals and leads from HFPP Analytics
• Collaborate on the development of HFPP analytic reports
• Drive outcome metrics related to fraud, waste, and abuse referrals and leads shared with Partners
• May perform business development activities including analyzing health claims data, generating study referrals and leads, developing provider background profiles, and identifying opportunities for Partner collaboration meetings
• Reviews and analyzes medical claims to determine accuracy, completeness and compliance with insurance policies, coding guidelines and reimbursement criteria.
• Identify fraud, waste, and abuse schemes and conduct research and investigation of insurance policies, coding guidelines and reimbursement criteria
• Participates in quality assurance initiatives to ensure deliverable adherence to regulatory requirements, medical and company policies and industry standards.
• Evaluates and responds to analytic output questions from internal and external parties.
• May coach and provide guidance to less experienced professionals.

WHAT YOU'LL NEED TO SUCCEED (REQUIRED):

• Bachelors degree or equivalent year of work experience
• 8+ years' experience in healthcare claims analysis
• Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)
• Expertise in medical terminology and all healthcare coding (e.g., ICD-10, CPT, HCPCS)
• Experience in program integrity and healthcare fraud, waste, and abuse activities, including edits, audits, pre-payment and post-payment review, investigations, referrals
• Extensive knowledge of insurance regulations, reimbursement methodologies and healthcare compliance requirements.
• Strong oral and written communication skills with the ability to present to management level staff.
• Expert level knowledge of Microsoft Office suite.
• Experience with Tableau, Amazon WorkSpaces, Jira, and Confluence.
• Working knowledge of HIPAA privacy and security rules.

WHAT WOULD BE EVEN BETTER (PREFERRED):

• Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation strongly desired.

SKILL & ATTRIBUTES FOR SUCCESS:

• Strong decision-making skills and a demonstrated history of established leadership qualities as well as proven organizational skills.
• Commitment to confidentiality, privacy, and professionalism.
• Ability to independently follow through on problems.
• Detail oriented and ability to prioritize multiple tasks and work under pressure.
• Ability to work on complex projects with general direction and minimal guidance
• Ability to build effective relationships, demonstrating strong interpersonal skills.
• Exhibit high initiative to get things accomplished; high organizational ability to juggle multiple priorities.
• Ability to perform well and achieve goals both in a team environment, with staff at all levels, and independently.