We are seeking a highly qualified candidate for a Clinical Certified Coder role within our client's Special Investigations Unit. The Clinical Coder will support the organization in the detection, prevention and investigation of suspected fraud, waste, and abuse. 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 regulations and company 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 on 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 required - 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. 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. Preferred candidate will have experience in Medicaid, Medicare, and Marketplace/Exchange. Licensure and/or Certification Required: Registered Nurse (RN) - Required. AAPC Coding certification - Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA), or Certified Coding Specialist (CCS) - Required. Professional Competencies: Integrity and Trust Customer Focus Excellent Microsoft Office Suite skills Written/Oral Communication Please note that the salary range and/or hourly rate range of $60.00 to $65.00 is a good faith determination of potential base compensation offered to applicants at the time of this job advertisement and may be subject to modification in the future. When determining a team member's base salary and/or hourly rate, various factors may be taken into account as applicable (such as location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget, and internal equity). For consideration to this and/or other roles suitable for your background, please submit your most up-to-date resume to join our talent pool. At ATRIA Consulting, LLC, we are a woman-owned business that is fully committed to promoting, cultivating, and maintaining a culture of diversity, equity, and inclusion. We pledge to continue the fight against racism and any other form of bias. We embrace and celebrate our employees' differences in age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make us all unique. We are the collective sum of individual differences, life experiences, knowledge, innovation, self-expression, inventiveness, and talent. We encourage everyone to apply!
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