The Certified Professional Coder (CPC) will perform medical claim reviews for the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record review for medical, behavioral, transportation, and other healthcare providers. The role requires determining correct coding and appropriate documentation, ensuring state, federal, and company requirements are met, and identifying concerning billing patterns or trends.
- Conduct comprehensive medical record audits to verify billed CPT/HCPCS codes and modifiers match documentation.
- Prepare detailed written summaries of medical record review findings.
- Communicate findings to investigators, leadership, law enforcement, legal counsel, providers, and regulators.
- Research and apply state and CMS guidelines related to audits.
- Review cases with Medical Directors to validate decisions.
- Assist with investigative research related to coding questions and policy interpretation.
- Identify potential billing errors, abuse, fraud, and opportunities for prepayment review.
- Maintain accurate records, files, and documentation.
- Work with department resources and workflows to meet performance metrics.
Requirements & Qualifications
- AAPC Coding certification / Certified Professional Coder (CPC)
- 3+ years of experience in medical coding or documentation auditing
- Strong knowledge of CPT, HCPCS, ICD-10, CMS 1500, and UB04 data elements
- Up-to-date knowledge of coding compliance and reimbursement changes
- Experience researching coding guidelines and policies
- Proficiency with Microsoft Excel and Word
- Strong attention to detail and ability to review and interpret data
- Strong communication skills
- GED or high school diploma
- Preferred: prior auditing experience
- Preferred: excellent analytical skills
- Preferred: 2+ years of behavioral health coding/auditing experience
Benefits & Perks
- Comprehensive medical, dental, and vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Bonus, commission, or short-term incentive eligibility
- Additional benefits available based on eligibility
Location
Connecticut, US
Employment Type
Full-time
Experience Level
Intermediate Level
Salary Range
$43,888 - $93,574
Remote work allowed
No
Posted
2 weeks ago
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