Special Investigations Unit Clinical Certified Coder - New York, NY

MetroPlus; New York (NY); Hybrid; USD 60,000 - 80,000; Full time

Job summary

MetroPlus is seeking a Clinical Coder to join its Special Investigations Unit in New York City. The candidate will review medical records and claims for compliance, conduct audits, and participate in investigations of suspected fraud.

A Bachelor's degree in Nursing and AAPC Coding certification are required, along with 5+ years of relevant experience. Strong analytical skills and attention to detail are essential for success in this role.

The position allows for hybrid work arrangements, promoting both collaboration and work-life balance.

Qualifications

• 5 years of experience in healthcare fraud detection, investigation, or auditing.
• In-depth experience and knowledge of coding regulations including ICD-10, CPT, and HCPCS.
• Valid New York State license as a Registered Professional Nurse.

Responsibilities

• Review medical records and healthcare claims for compliance.
• Conduct audits of high-risk claims to ensure adherence to regulations.
• Create detailed reports with findings and corrective actions.

Skills

Integrity and Trust

Customer Focus

Strong communication skills

Strong analytical skills

Attention to detail

Education

Bachelor’s degree in Nursing or related fields

AAPC Coding certification

Tools

Microsoft Office Suite

Job description

Empower. Unite. Care.

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that healthcare 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.

Position Overview

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

#LI-Hybrid #MPH50