SIU Investigator

Healthcare Fraud Shield; Chesterfield (MO); Remote; USD 50,000 - 80,000; Full time

Job summary

An established industry player in healthcare fraud prevention is seeking a skilled Coder or Clinical Coder/Fraud Investigator. In this role, you will work closely with a dedicated team to analyze patient medical records and ensure accurate billing and reimbursement. Your expertise in medical coding and attention to detail will be essential in conducting fraud investigations and maintaining compliance with industry regulations. This position offers the opportunity to contribute significantly to the integrity of healthcare services while enjoying a flexible work environment, including remote work options. If you are passionate about making a difference in healthcare, this is a fantastic opportunity for you.

Benefits

401(k) retirement savings with employer match

Vacation and sick paid time off

8 paid holidays

Paid maternity/paternity leave

Disability & Life insurance

Flexible Spending Account (FSA)

Employee Assistance Program (EAP)

Professional and career development initiatives

Qualifications

• Must have CPC certification or equivalent and at least one year of coding experience.
• Detail-oriented with strong knowledge of medical coding guidelines.

Responsibilities

• Analyze patient medical records for fraud investigations.
• Perform quality checks and assist in coding determinations.
• Document findings and maintain compliance with privacy standards.

Skills

Knowledge of medical terminology

Knowledge of coding (CPT, HCPCS, Revenue Codes, DRG Codes, ICD-10)

Detail oriented

Effective communication (verbal and written)

Ability to meet performance and production goals

Education

Certified Professional Coder (CPC)

Minimum of one year of coding and/or billing experience

Job 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.

RESPONSIBILITIES

• Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts) including performing quality checks on work, assisting in research, and discussing 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.
• Determine appropriateness of billing and reimbursement as needed.
• Document findings for each claim line in a spreadsheet as needed.
• Summarize findings in a written report as needed.
• Abstract CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed.
• Maintain 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.
• Understand and comply 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.

KNOWLEDGE, SKILLS, & ABILITIES

• 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.
• Responsible.
• Ability to meet defined performance and production goals.
• 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

• 401(k) retirement savings with employer match.
• Vacation and sick paid time off.
• 8 paid 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