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.
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