The Role
Perform routine medical coding audits comparing billed CPT, HCPCS, ICD-10, DRG and revenue codes to medical records, document findings, summarize reports, and maintain knowledge of coding guidelines and regulations while meeting productivity targets.
Summary Generated by Built In
The Coding Auditor is a professional auditing role designed for a certified professional coder. Under direct supervision of Healthcare Fraud Shield SIU management, this position executes routine coding reviews to ensure health records align accurately with billed ICD-10-CM, CPT, HCPCS, Revenue codes. The ideal candidate has a strong foundation in primary medical coding and a keen eye for detail, eager to learn complex audit frameworks, regulatory policies, and documentation validation.
Key Responsibilities
- Compare the procedures and codes billed on a claim to a medical record.
- Compare information submitted on the claims in order to determine amount and nature of billable services as needed.
- Determines appropriateness of billing and reimbursement as needed.
- Documents findings for each claim line in a spreadsheet as needed.
- Summarize findings in a written report as needed.
- Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-10 from medical records as needed.
- Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed.
- Understands and complies with all company Privacy and Security standards.
- Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law.
- On average, there are a minimum of 5-10 claim line reviews per hour.
- Other duties as needed.
Skills, Knowledge and Expertise
- Knowledge of medical terminology.
- Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10.
- Knowledge of specialty medical practices.
- Must be detail oriented.
- Ability to communicate effectively both verbally and in writing.
- Strong listening skills.
- Independent.
- Responsible.
- Self-disciplined.
- Ability to meet defined performance and production goals.
- Strong computer skills.
- This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
Certificate/License:
- Minimum of one year of investigative experience is required.
- Required to have one of the following: CPC, CCS, CCA
Benefits
- Medical, Dental & Vision insurance
- 401(k) retirement savings with employer match
- Vacation and sick paid time off
- 7 paid holidays & 2 floating holidays
- Paid maternity/paternity leave
- Disability & Life insurance
- Flexible Spending Account (FSA)
- Employee Assistance Program (EAP)
- Professional and career development initiatives
- Remote work eligible
REMOTE WORK REQUIREMENTS:
- Must have high speed Internet (satellite is not allowed for this role) with a minimum speed of 25mbs download and 5mbs upload.
Healthcare Fraud Shield is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
About
Healthcare Fraud Shield, headquartered in Chesterfield, MO, is a leading provider of innovative fraud, waste, and abuse (FWA) solutions for healthcare insurance payers. Since its establishment in 2011, the company has focused solely on healthcare fraud prevention and payment integrity, delivering unique advantages to its broad client base. At the heart of Healthcare Fraud Shield's offerings is FWAShield™, an integrated platform designed by industry-leading healthcare experts. This comprehensive solution includes PreShield™ (pre-payment), PostShield™ (post-payment), RxShield™ (pharmacy analytics), CaseShield™ (case management), and QueryShield™ (ad-hoc querying tool). Leveraging the latest technology available, Healthcare Fraud Shield provides the most affordable, flexible, transparent, efficient, and effective solution in the marketplace. With over 20 years of experience, the founders of Healthcare Fraud Shield are pioneers in successful fraud detection software development in the financial services industry. They have designed their suite of software to identify superior FWA rates, utilizing advanced analytics, AI, and the best exterior data. Additionally, Healthcare Fraud Shield offers expert services in detecting and verifying suspected FWA billed services, including the development of claim edit rules. Their experienced SIU team, which includes Accredited Health Care Fraud Investigators and Certified Professional Coders, delivers top-notch training throughout the country. Trust Healthcare Fraud Shield to safeguard your healthcare insurance payments and ensure payment integrity.
Skills Required
- Minimum of one year of investigative experience
- CPC, CCS, or CCA certification
- Knowledge of medical terminology
- Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10
- Knowledge of specialty medical practices
- Detail oriented with ability to meet defined performance and production goals (5-10 claim line reviews per hour)
- Effective verbal and written communication and strong listening skills
- Ability to work independently, be responsible and self-disciplined
- Strong computer skills and secure information management
- Remote work: high-speed internet minimum 25mbs download and 5mbs upload (satellite not allowed)
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The Company
What We Do
Healthcare Fraud Shield provides AI-powered SaaS solutions and dynamic software to detect and prevent healthcare fraud, waste, abuse, and error (FWAE) across the claims lifecycle.
