The Role
Conducts healthcare fraud, waste, and abuse investigations by reviewing medical records and claims, validating coding and billing appropriateness, abstracting clinical and billing codes, analyzing client data, documenting claim findings, preparing reports, and supporting Special Investigations Unit clients. Requires maintaining knowledge of coding guidelines, healthcare regulations, privacy standards, and secure handling of protected health information.
Summary Generated by Built In
Healthcare Fraud Shield, a leader in healthcare fraud prevention and payment integrity solutions, is looking for a talented Clinical Coder/Fraud Investigator to join our team.
Key Responsibilities
- Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed).
- Analyze and interpret patient medical records pertaining to FWA investigations as needed.
- Compare information submitted on the claims to determine the 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-9/ICD-10 from medical records as needed.
- Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed.
- Perform data analysis of client data as needed.
- Conduct various aspects of FWA investigations as needed.
- Provide Subject Matter Expertise and SIU support to clients as needed.
- Comply with Privacy and Security standards.
- 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.
- 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:
- Certified Professional Coder - (CPC®) through governing body AAPC.
- Minimum of one year of coding and/or billing experience is required.
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
- Certified Professional Coder certification through AAPC
- At least one year of coding and/or billing experience
- Knowledge of medical terminology
- Knowledge of CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10 coding
- Knowledge of specialty medical practices
- Strong computer skills
- Ability to communicate effectively verbally and in writing
- Ability to meet defined performance and production goals
- High-speed internet with at least 25 Mbps download and 5 Mbps upload; satellite internet is not allowed
- Ability to securely manage confidential and sensitive information
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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.
