Job Description

:: Senior executive SIU Investigator (Special Investigation Unit)More than 5 years of experience in surgery coding is a must.The Fraud and Waste Professional conducts investigations of allegations of fraudulent and abusive practices and assists investigators with law enforcement activities. The Senior Specialist, Medical Coding Auditor, SIU, works to support in assessing trends and patterns in FWA across the healthcare industry using deep coding knowledge to audit prepayment and/or post payment claims. Assembles evidence and documentation to support successful adjudication, where appropriate. Conducts audits of provider records ensuring appropriateness of billing practices and coding services rendered is complete, compliant, and accurate to support optimal reimbursement.Understands own work area professional concepts/standards, regulations, strategies, and operating standards. Makes decisions regarding own work approach/priorities and follows direction. Work is managed and often guided by precedent and/or documented procedures/regulations/professional standards with some interpretation.Responsibilities:

• Develops and maintains a depth of expertise on CPT, HCPCS, and ICD-10 Coding guidelines and other insurance billing submission requirements.
• Perform complex policy updates or audits of assigned documentation (i.e. medical records or claims) on both a prepayment and/or post payment basis to determine accuracy of claims.
• Understanding of healthcare industry, claims processing and investigative process.

Education: Bachelor's or Advanced degree in Nursing or related field.Experience: Five years coding or auditing experience across multiple specialties in the health insurance industry and/or healthcare fraud investigations. Preferred qualifications include one-year leading projects of varying size and complexity, three years of financial analysis in a healthcare setting, and three years in professional billing.Licenses/Certifications: Certified Professional Coder (CPC), Certified Coding Specialist (CCS)Skills: Knowledge of provider payment methodologies claims processing systems, coding and billing; strong computer skills and the ability to use data mining tools; excellent communication (written and oral); relationship-building skills; strong business acumen; ability to work independently and as part of a team; and problem-solving capabilities; knowledge and understanding of healthcare fraud schemes and trends are key. Emphasis on serving as a subject matter expert, providing guidance and training to other team members, and potentially leading special projects. Strong ability to comprehend and explain complex processes end-to-end and identify risks and mitigating controls.

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