Medical Coder

W3R Consulting; Illinois; On-site; USD 70,000 - 110,000; Full time

Job summary

W3R Consulting seeks an experienced healthcare auditor to investigate complex claims and verify coding accuracy before payment. You will combine clinical coding expertise with investigative rigor to ensure medical necessity and regulatory compliance across CPT, HCPCS, ICD-10-CM/PCS coding standards.

Please lead pre‑payment reviews, identify fraud or non‑compliance patterns, and prepare audit summaries to inform SIU or Compliance teams as warranted.

Qualifications

• RN license required with active status.
• Certifications in medical coding (CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA) mandatory.
• Minimum 5 years in clinical auditing, medical coding, or related healthcare compliance.

Responsibilities

• Triages allegations and investigates third‑party referrals before payment.
• Reviews medical records to verify coding accuracy and medical necessity.
• Audits documentation to ensure CPT, HCPCS, ICD-10-CM/PCS alignment with guidelines.
• Summarizes findings and supports referrals to SIU or Compliance teams when needed.

Skills

Auditing

Claims analysis

Medical coding

Medical record review

Regulatory compliance

Education

RN license

Certified medical coder (CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA)

Job description

Description:

Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations.

Key responsibilities:

• Allegation Triaging & Investigation: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services.
• Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis.
• Pre-Payment Clinical Review: Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized for payment.

• Coding & Documentation Validation: Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.
• Medical Necessity Assessment: Evaluate medical records against internal medical policies, prepare review summary as needed and work closely with Medical Directors
• Prepare audit summaries and support referrals to Special Investigations Unit (SIU), Provider Performance, or Compliance teams when warranted.

Required Qualifications & Education:

• Education: Nursing RN, active license
• Core Coding Credentials: Must hold at least one active, nationally recognized coding certification:
  • AAPC: Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC) or Certified Professional Medical Auditor (CPMA).
  • AHIMA: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), or Registered Health Information Technician/Administrator (RHIT/RHIA).

• Experience: 5 years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, utilization management, or healthcare compliance, or related healthcare reimbursement functions, including medical record review and claims auditing.

Technical Expertise:

• Demonstrated proficiency in CPT, HCPCS Level II, ICD-10-CM, and medical record documentation review.
• Working knowledge of CMS reimbursement methodology, National Correct Coding Initiative (NCCI) edits, and applicable federal and state regulations.

Prefer:

• Behavioral Health coding and auditing experience.
• Knowledge of DSM-5 documentation requirements.
• Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims.