Remote Investigator, Coding SIU - Full Time Opportunity with a Leading Healthcare Organization

Unlock a Rewarding Career in Healthcare Fraud Investigation

Join our team as a Remote Investigator, Coding SIU, and embark on a challenging and fulfilling career journey in the healthcare industry. As a key member of our Special Investigations Unit (SIU), you will play a critical role in identifying and preventing healthcare fraud and abuse, ensuring the integrity of our healthcare system.

About Our Organization

Our organization is a leading healthcare provider committed to delivering high-quality, cost-effective healthcare solutions to our members. We operate in a dynamic environment, constantly evolving to meet the changing needs of our members and the healthcare landscape. Our SIU team is dedicated to protecting our members and our organization from healthcare fraud and abuse, and we are seeking a skilled and motivated Investigator, Coding SIU to join our team.

Job Summary

As a Remote Investigator, Coding SIU, you will be responsible for investigating and resolving instances of healthcare fraud and abuse by medical providers. Your primary focus will be on conducting post-pay clinical reviews, analyzing data to identify potential fraud, waste, and abuse (FWA), and collaborating with law enforcement and other stakeholders to facilitate payment recovery and referrals.

Key Responsibilities

• Conduct thorough reviews of post-pay claims and corresponding medical records to determine the accuracy of claims payments.
• Analyze applicable policies, CPT guidelines, and provider contracts to identify potential FWA.
• Develop clinical summaries post-review and communicate findings to relevant stakeholders.
• Participate in meetings related to cases and collaborate with team members to share knowledge and best practices.
• Utilize critical thinking, problem-solving, and analytical skills to identify FWA trends and patterns.
• Prioritize and manage multiple tasks to ensure timely turnaround and meet productivity standards.
• Demonstrate excellent oral and written communication skills, with the ability to present findings to various audiences.

Essential Qualifications

To be considered for this role, you must meet the following essential qualifications:

• High School Diploma or GED (or higher).
• 3+ years of CPT coding experience (surgical, hospital, clinic settings) or 5+ years of experience working in a FWA/SIU or Fraud investigations role, preferably in New Jersey or New York.
• Certified Coder (CPC, CCS, and/or CPMA).
• Thorough knowledge of PC-based software, including Microsoft Word and Microsoft Excel.

Preferred Qualifications

While not mandatory, the following preferred qualifications will be considered a plus:

• 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, and Federal laws and regulations pertaining to health insurance, investigations, and legal processes.
• Experience with UNET, Comet, Macess/CSP, or other similar claims processing systems.
• AAPC Certified Medical CPC, CPMA, CPCO, or similar specialist.
• Certified Fraud Examiner and/or AHFI professional designations.

Skills and Competencies

To succeed in this role, you will need to possess the following skills and competencies:

• Strong analytical and problem-solving skills, with the ability to analyze complex data and identify patterns.
• Excellent communication and presentation skills, with the ability to communicate findings to various audiences.
• Ability to prioritize and manage multiple tasks, with a strong attention to detail.
• Proven ability to work in a team setting, with a collaborative and flexible mindset.
• Strong knowledge of CPT coding guidelines, medical terminology, and healthcare regulations.

Career Growth Opportunities and Learning Benefits

As a Remote Investigator, Coding SIU, you will have opportunities for career growth and professional development within our organization. You will be working with a talented team of professionals who are dedicated to excellence and committed to ongoing learning and improvement. Our organization offers a range of training and development programs to support your career advancement, including:

• Ongoing training and education on healthcare regulations, coding guidelines, and industry best practices.
• Opportunities for career advancement within our SIU team or other areas of our organization.
• Mentorship and coaching from experienced professionals.

Work Environment and Company Culture

Our organization is committed to creating a positive and inclusive work environment that supports the well-being and success of our employees. As a remote worker, you will be part of a distributed team that values flexibility, collaboration, and open communication. We offer a range of benefits and perks to support your work-life balance, including:

• Competitive salary and benefits package.
• Flexible work arrangements, including remote work options.
• Ongoing training and development opportunities.
• A culture of recognition and reward, with opportunities for career advancement.

Compensation, Perks, and Benefits

We offer a competitive compensation package, including a salary and benefits that reflect your skills and experience. Our benefits package includes:

• Medical, dental, and vision insurance.
• Retirement savings plan.
• Paid time off and holidays.
• Ongoing training and development opportunities.

Join Our Team!

If you are a motivated and detail-oriented professional with a passion for healthcare and a commitment to excellence, we encourage you to apply for this exciting opportunity. As a Remote Investigator, Coding SIU, you will play a critical role in our organization's mission to protect our members and our healthcare system from FWA. Don't hesitate to apply - we look forward to hearing from you!