Certified Coding Investigator

Job Summary

To support the Special Investigative Unit, the full-time Certified Coding Investigator will investigate and resolve instances of healthcare fraud, waste, and abuse by reviewing medical claims and records while working remotely.

Key responsibilities

• Independently re-evaluates medical claims and associated records for accuracy based on coding standards and regulations
• Manages documentation and prioritizes caseloads to ensure timely resolution of investigations
• Communicates findings and participates in meetings related to cases, facilitating referrals to law enforcement when necessary

Required qualifications

• At least 2 years of CPT coding experience in a surgical, hospital, and/or clinic setting
• Certification as a Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or similar credential
• Knowledge of managed care, Medicaid, Medicare, and Marketplace programs
• Understanding of claim billing codes, medical terminology, and healthcare delivery systems
• Ability to research and interpret regulatory requirements effectively