Investigator, Coding SIU (Remote)
About the position Responsibilities • Investigate and resolve instances of healthcare fraud and abuse by medical providers. • Review post-pay claims with corresponding medical records to determine accuracy of claims payments. • Review applicable policies, CPT guidelines, and provider contracts. • Devise clinical summary post review. • Communicate and participate in meetings related to cases. • Manage documents and prioritize case load to ensure timely turnaround. • Complete medical reviews to facilitate referrals to law enforcement or for payment recovery. Requirements • High School Diploma / GED (or higher). • 3+ years CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience in a FWA/SIU or Fraud investigations role. • Thorough knowledge of PC based software including Microsoft Word and Microsoft Excel. • Licensed registered nurse (RN), Licensed practical nurse (LPN) and/or Certified Coder (CPC, CCS, and/or CPMA). Nice-to-haves • Bachelor's degree (or higher). • 2+ years of experience working in the group health business, particularly within claims processing or operations. • Demonstrated working knowledge of Local, State & Federal laws and regulations pertaining to health insurance, investigations & legal processes. • Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems. • Demonstrated ability to use MS Excel/Access platforms working with large quantities of data. Benefits • Competitive benefits and compensation package. Apply tot his job