Medical Coder

W3R Consulting; United States; Vor Ort; USD 90.000 - 130.000; Vollzeit

Zusammenfassung

W3R Consulting is seeking an experienced Healthcare Claims Auditor with an active RN license and coding credentials. You will conduct pre-payment reviews, validate documentation against CPT/HCPCS/ICD-10-CM, and assess medical necessity across complex claims.

The role requires strong analytical skills and familiarity with CMS rules, NCCI edits, and state/federal regulations. Prior SIU or compliance collaboration is a plus.

Qualifikationen

• RN license active and required
• 5 years of combined experience in clinical auditing, medical coding, or related healthcare compliance
• Must hold at least one active coding certification (CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA)
• Proficiency in CPT, HCPCS Level II, ICD-10-CM/PCS and medical record documentation review

Aufgaben

• Triaging and investigating third-party referrals, tips, and external fraud allegations to identify billing patterns
• Identify fraud, waste, abuse, and non-compliance through medical record review and claims analysis
• Pre-payment clinical review of high-value or complex records before payment
• Audit clinical documentation for alignment with coding guidelines and medical necessity
• Prepare summaries and support referrals to SIU or Compliance when warranted

Kenntnisse

Attention to detail

Analytical thinking

Regulatory knowledge

Ausbildung

RN license

CPC/COC/CIC/CPMA or CCS/CCS-P/RHIT/RHIA

Tools

CPT

HCPCS Level II

ICD-10-CM/ICD-10-PCS

Jobbeschreibung

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.