SIU Clinical Coder & Fraud Investigator

MetroPlusHealth; New York (NY); On-site; USD 70,000 - 90,000; Full time

Job summary

MetroPlusHealth in New York seeks a Clinical Certified Coder to support fraud detection and investigations in the Special Investigations Unit. The successful candidate will review medical records and claims, conduct audits, and collaborate with the team on suspected fraudulent activities.

A minimum of 5 years of relevant experience and AAPC coding certification are required. This role emphasizes strong analytical skills, communication, and integrity in handling sensitive healthcare information.

Qualifications

• At least 5 years of experience in healthcare fraud detection or auditing.
• In-depth knowledge of coding regulations including ICD-10, CPT, HCPCS.
• Preferred experience in Medicaid, Medicare, and Marketplace/Exchange.

Responsibilities

• Review medical records and claims for accuracy and compliance.
• Conduct high-risk claim audits to detect fraud.
• Collaborate with SIU team to evaluate suspected fraud.
• Create detailed reports with findings and recommendations.
• Assist in discussions with providers about findings.
• Present findings to stakeholders and leadership.
• Maintain thorough documentation of investigations.
• Stay updated on coding guidelines and fraud detection methods.
• Complete special projects and audits as required.

Skills

Integrity and Trust

Customer Focus

Excellent Microsoft Office Suite skills

Strong communication skills

Strong analytical skills

Education

Bachelor’s degree in Nursing or related field

AAPC coding certification (CPC, CPMA, or CCS)

Job description

MetroPlusHealth in New York seeks a Clinical Certified Coder to support fraud detection and investigations in the Special Investigations Unit. The successful candidate will review medical records and claims, conduct audits, and collaborate with the team on suspected fraudulent activities.

A minimum of 5 years of relevant experience and AAPC coding certification are required. This role emphasizes strong analytical skills, communication, and integrity in handling sensitive healthcare information.