Healthcare Coding Expert (certified professional coder)

General Dynamics Information Technology, Inc.; United States; Remote; USD 100,000 - 140,000; Full time

Job summary

General Dynamics Information Technology, Inc. is seeking a Healthcare Coding Expert to support CMS initiatives. You will analyze healthcare claims, identify fraud indicators, and develop referrals for HFPP partners and trusted third parties.

The role requires CPC/CCS certification, extensive coding knowledge (ICD-10, CPT, HCPCS) and strong communication skills. You will work with Tableau, Jira, Confluence and MS Office in a large, mission-focused team.

Qualifications

• Bachelor's degree or equivalent year of work experience is required.
• 8+ years' experience in healthcare claims analysis.
• Certified CPC (AAPC) or CCS (AHIMA) certifications are required.
• Expertise in ICD-10, CPT, HCPCS and medical terminology.
• Experience with program integrity and healthcare fraud, waste, and abuse activities.

Responsibilities

• Identify fraud, waste, and abuse referrals and leads from HFPP Analytics.
• Collaborate on HFPP analytic reports development.
• Drive metrics for referrals and leads shared with Partners.
• Conduct health claims data analysis and generate study referrals and leads.
• Review medical claims for accuracy and coding guideline compliance.
• Investigate insurance policies and coding guidelines for compliance.
• Support QA to meet regulatory and policy standards.
• Respond to analytics questions from internal and external parties.
• Mentor and guide less experienced professionals.

Skills

CPC

CCS

Medical coding

ICD-10

CPT/HCPCS

Fraud analytics

HIPAA

Communication

Education

Bachelor's degree or equivalent experience

Tools

Tableau

Jira

Confluence

Microsoft Office

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.