Healthcare Coding Expert – Certified Professional Coder

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct analytical tasks that support the Healthcare Fraud Prevention Partnership (HFPP) program.

• Detect referrals and leads related to fraud, waste, and abuse from HFPP Analytics.

• Collaborate in the creation of HFPP analytic reports.

• Drive outcome metrics for fraud, waste, and abuse referrals and leads shared with Partners.

• Analyze health claims data to produce study referrals and leads.

• Develop comprehensive provider background profiles.

• Identify opportunities to facilitate Partner collaboration meetings.

• Review and evaluate medical claims for accuracy, completeness, and compliance with insurance policies, coding guidelines, and reimbursement criteria.

• Recognize schemes related to fraud, waste, and abuse.

• Research and examine insurance policies, coding guidelines, and reimbursement criteria.

• Participate in quality assurance initiatives to ensure deliverables meet regulatory requirements, medical and company policies, and industry standards.

• Assess and address analytic output inquiries from both internal and external stakeholders.

• Mentor and provide support to less experienced professionals as needed.

• Assist CMS as part of a 50-person team supporting the Trusted Third Party aimed at reducing healthcare fraud, waste, and abuse.

⛳️ Requirements

• Bachelor's degree or an equivalent amount of work experience.

• A minimum of 8 years’ experience in healthcare claims analysis.

• Certification as a Professional Coder (CPC) from the American Academy of Professional Coders (AAPC) or as a Certified Coding Specialist (CCS) from the American Health Information Management Association (AHIMA).

• Proficiency in medical terminology and healthcare coding, including ICD-10, CPT, and HCPCS.

• Experience in program integrity and activities related to healthcare fraud, waste, and abuse, such as edits, audits, pre-payment and post-payment review, investigations, and referrals.

• In-depth understanding of insurance regulations, reimbursement methodologies, and healthcare compliance requirements.

• Strong oral and written communication abilities, with the capability to present to management-level personnel.

• Expert-level proficiency in the Microsoft Office suite.

• Familiarity with Tableau, Amazon WorkSpaces, Jira, and Confluence.

• Knowledge of HIPAA privacy and security regulations.

• Certification as a Fraud Examiner (CFE) or as an Accredited Healthcare Fraud Investigator (AHFI) is highly preferred.

• Strong decision-making, organizational, and leadership skills.

• A commitment to confidentiality, privacy, and professionalism.

• Ability to independently resolve issues.

• Detail-oriented with the capability to prioritize multiple tasks and perform under pressure.

• Capacity to work on complex projects with general direction and minimal supervision.

• Ability to cultivate effective relationships and showcase strong interpersonal skills.

• Competence to work effectively both independently and within team settings.

• No work visa sponsorship; US citizenship is not a requirement.

🏝️ Benefits

• Options for medical plans, some inclusive of Health Savings Accounts.

• Choices for dental plans.

• Options for vision plans.

• 401(k) plan with pre-tax and post-tax contributions along with company matching.

• Flexible work weeks where feasible.

• Paid vacation, sick leave, and personal time.

• Paid holidays.

• Paid parental, military, bereavement, and jury duty leave.

• Generally, 15 days of paid leave each calendar year.

• An additional 10 paid holidays annually.

• Up to 160 hours of paid family leave within a rolling 12-month period for eligible employees.

• Short-term and long-term disability benefits available.

• Life insurance coverage.

• Accidental death and dismemberment insurance.

• Personal accident insurance.

• Critical illness insurance.

• Business travel and accident insurance.

• Identity verification process incorporating biometric data protection and security measures.