SIU Investigator

Healthcare Fraud Shield; Chesterfield (MO); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Remote work eligible

401(k) retirement savings with company

Vacation and sick paid time off

7 paid holidays & 2 floating holidays

Job summary

Healthcare Fraud Shield is seeking an SIU Investigator to join our team at headquarters. You will collaborate with the SIU group to review clinical records, analyze CPT/ICD coding, and contribute to fraud investigations supporting client engagements.

The role requires CPC certification, coding experience, strong analytical and communication skills, and the ability to manage multiple investigations while upholding privacy standards. Remote work eligible.

Qualifications

• Certified Professional Coder (CPC) certification required
• Minimum of one year coding and/or billing experience required

Responsibilities

• Work with SIU Team to review and discuss coding determinations
• Analyze patient medical records for FWA investigations
• Compare claims information to determine billable services
• Determine appropriateness of billing and reimbursement
• Document findings in spreadsheets and reports
• Abstract CPT/HCPCS/Revenue Codes/DRG/ICD-9/ICD-10 from records
• Maintain knowledge of coding guidelines and regulations
• Perform data analysis and data mining of client data
• Conduct FWA investigations and provide SIU support
• Adhere to Privacy and Security standards and protect PHI

Skills

Medical terminology

CPT coding

HCPCS coding

DRG coding

ICD-10 coding

Detail oriented

Verbal & written communication

Active listening

Independent

Responsible

Self-disciplined

Performance & production goals

Computer skills

Privacy & security compliance

Education

CPC certification

1+ year coding/billing experience

Job description

SIU Investigator

Department: SIU

Employment Type: Full Time

Location: Headquarters

Description

Healthcare Fraud Shield, a leader in healthcare fraud prevention and payment integrity solutions, is looking for a talented Coder or Clinical Coder/Fraud Investigator to join our team.

Key Responsibilities

• Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed)
• Analyze and interpret patient medical records (behavioral related and other specialties) pertaining to FWA investigations as needed
• Compare to information submitted on the claims in order to determine amount and nature of billable services as needed
• Determines appropriateness of billing and reimbursement as needed
• Documents findings for each claim line in a spreadsheet as needed
• Summarize findings in a written report as needed
• Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed
• Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed
• Perform data analysis and lead generation/data mining of client data as needed
• Conduct various aspects of FWA investigations as needed
• Provide Subject Matter Expertise and SIU support to clients as needed
• Comply with Privacy and Security standards
• Understands and complies with all company Privacy and Security standards
• Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law
• Other duties as needed

Skills, Knowledge and Expertise

• Knowledge of medical terminology
• Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10
• Knowledge of specialty medical practices
• Must be detail oriented
• Ability to communicate effectively both verbally and in writing
• Strong listening skills
• Independent
• Responsible
• Self-disciplined
• Ability to meet defined performance and production goals
• Strong computer skills
• This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management

CERTIFICATE/LICENSE

• Certified Professional Coder - (CPC®) through governing body AAPC or equivalent certification
• Minimum of one year of coding and/or billing experience is required.

Benefits

• Medical, Dental & Vision insurance
• 401(k) retirement savings with employer match
• Vacation and sick paid time off
• 7 paid holidays & 2 floating holidays
• Paid maternity/paternity leave
• Disability & Life insurance
• Flexible Spending Account (FSA)
• Employee Assistance Program (EAP)
• Professional and career development initiatives
• Remote work eligible

REMOTE WORK REQUIREMENTS

• Must have high speed Internet (satellite is not allowed for this role) with a minimum speed of 25mbs download and 5mbs upload.

Healthcare Fraud Shield is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.