Special Investigations Unit Clinical Certified Coder

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

Position Overview

MetroPlusHealth seeks a Clinical Certified Coder to support the Special Investigations Unit in detecting, preventing, and investigating suspected fraud, waste, and abuse. The role reports to the Director of the Special Investigations Unit.

Scope of Role & Responsibilities

• Review medical records and claims to determine accuracy and compliance with regulations.
• Conduct high‑risk claim audits to detect potential fraud, waste, and abuse.
• Collaborate with the SIU team to evaluate suspected fraudulent activities such as over‑utilization, upcoding, and non‑medically necessary services.
• Create detailed reports with findings, rationale, sources, and corrective action recommendations.
• Assist in provider calls to discuss findings and rationale.
• Present findings to leadership and stakeholders to facilitate FWA proceedings.
• Prepare documentation for audits, recoupments, compliance/legal reviews, and regulatory inquiries.
• Maintain thorough documentation of investigations, including findings, coding discrepancies, and communication with providers and investigators.
• Stay updated on coding guidelines, healthcare regulations, and fraud detection methods.
• Complete special projects and audits as required.

Required Education, Training & Professional Experience

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

Licensure And/or Certification Required

• AAPC coding certification - Certified Professional Coder (CPC) or Certified Professional Medical Auditor (CPMA) or Certified Coding Specialist (CCS).
• 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.