MetroPlusHealth

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. #J-18808-Ljbffr

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...