Special Investigations Unit Clinical Certified Coder

MetroPlusHealth; New York (NY); On-site; USD 85,000 - 125,000; Full time

Job summary

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.

Responsibilities

• 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.

Skills

Healthcare auditing

Regulatory coding knowledge (ICD-10,  

Education

AAPC CPC

CPMA or CCS

Bachelor’s degree in Nursing/Medical Billing/Coding

Job description

Empower. Unite. Care.

Empower. Unite. Care.
MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

About NYC Health + Hospitals

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

MetroPlusHealth is seeking a highly qualified candidate for a Clinical Coder role within our Special Investigations Unit. The Clinical Certified Coder will support the Plan in the detection, prevention and investigation of suspected fraud, waste, and abuse. The position reports to the Director of Special Investigations Unit.

Scope Of Role & Responsibilities

• Review medical records and healthcare claims to determine the accuracy and compliance of billed codes with appropriate regulations, standards, policies and procedures.
• Conduct audits of high-risk claims and billing patterns to ensure adherence to healthcare regulation and
• MetroPlusHealth policy and detect potential FWA.
• Collaborate with other SIU team members to evaluate suspected cases of fraudulent activities, such as over-utilization of services, upcoding, and billing for non-medically necessary services.
• Create detailed reports with medical review findings that include research, rationale, sources and corrective action recommendations to the SIU Department. The reports will also validate whether audited claims should be denied, recouped and if other mitigation strategies are required.
• Participate as needed on provider calls to discuss findings and rationale of medical review.
• Present findings to leadership and other stakeholders to facilitate all FWA proceedings.
• Assist in preparing documentation for audits, recoupments, compliance/legal reviews and regulatory inquiries.
• Maintain thorough documentation of investigations, including clinical findings, coding discrepancies and all communication with healthcare providers and investigators.
• Stay updated to changes to coding guidelines, healthcare regulations, and fraud detection methods to ensure compliance and effective investigations.
• Completes special projects and audits as required.

Required Education, Training & Professional Experience

• 5 years of experience in healthcare fraud detection, investigation, or auditing
• In depth experience and knowledge of coding regulations including ICD-10, CPT, HCPCS, AMA etc.
• AAPC Coding certification - Certified Professional Coder (CPC), Certified Professional Medical
• Auditor (CPMA) or Certified Coding Specialist (CCS)
• Bachelor’s degree in Nursing, Medical Billing/Medical Coding, Healthcare or other related fields
• Preferred candidate will have experience in Medicaid, Medicare, and Marketplace/Exchange

Licensure And/or Certification Required

• AAPC Coding certification - Certified Professional Coder (CPC), Certified Professional Medical
• Auditor (CPMA) or Certified Coding Specialist (CCS) - Required
• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Excellent Microsoft Office Suite skills
• Strong communication skills to interact with providers, medical management, legal teams, and compliance departments.
• Strong analytical, research and problem-solving aptitude with attention to detail and accuracy

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