SIU Clinical Coder: Fraud Detection & Compliance

MetroPlusHealth; New York (NY); Sur place; USD 85 000 - 125 000; Plein temps

Résumé du poste

MetroPlusHealth seeks a Clinical Coder within the Special Investigations Unit to support detection, prevention, and investigation of fraud, waste, and abuse. The role involves reviewing medical records and claims to ensure billing accuracy and regulatory compliance, and preparing detailed findings for leadership.

The ideal candidate has 5+ years in healthcare fraud detection or auditing, CPC certification (or CPMA/CCS), and a NY RN license.

Qualifications

• 5 years of experience in healthcare fraud detection, investigation, or auditing.
• In depth experience and knowledge of coding regulations: ICD-10, CPT, HCPCS, AMA.
• Auditor (CPMA) or CCS certification and CPC certification.

Responsabilités

• Review medical records and healthcare claims for accurate codes and compliance.
• Audit high‑risk claims and billing patterns to detect FWA.
• Create detailed reports with findings and corrective actions for SIU.
• Present findings to leadership and assist in regulatory inquiries.

Connaissances

Healthcare auditing

Regulatory coding knowledge (ICD-10,  

Formation

AAPC CPC

CPMA or CCS

Bachelor’s degree in Nursing/Medical Billing/Coding

Description du poste

MetroPlusHealth seeks a Clinical Coder within the Special Investigations Unit to support detection, prevention, and investigation of fraud, waste, and abuse. The role involves reviewing medical records and claims to ensure billing accuracy and regulatory compliance, and preparing detailed findings for leadership.

The ideal candidate has 5+ years in healthcare fraud detection or auditing, CPC certification (or CPMA/CCS), and a NY RN license.