SIU Investigator

Healthcare Fraud Shield•Chesterfield, MO

About The Position

Healthcare Fraud Shield is seeking a Coder or Clinical Coder/Fraud Investigator to support its Special Investigations Unit (SIU) in healthcare fraud prevention and payment integrity. The position involves reviewing medical records and claims, conducting fraud, waste, and abuse (FWA) investigations, performing coding and data analysis, documenting findings, and providing subject matter expertise and support to clients. The role requires compliance with company privacy and security standards and careful handling of protected health information. The position is remote-work eligible, subject to high-speed internet requirements.

Requirements

Certified Professional Coder (CPC®) certification through AAPC or equivalent certification.
At least one year of coding and/or billing experience.
Knowledge of medical terminology.
Knowledge of coding, including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10.
Knowledge of specialty medical practices.
Detail oriented.
Ability to communicate effectively verbally and in writing.
Strong listening skills.
Ability to work independently; responsible and self-disciplined.
Ability to meet defined performance and production goals.
Strong computer skills.
Ability to exercise ongoing discretion and securely manage confidential and sensitive information.
For remote work, high-speed internet with at least 25 Mbps download and 5 Mbps upload; satellite internet is not allowed.

Responsibilities

Work with SIU team members, including clinical reviewers, CPCs, investigators, and analysts; perform quality checks, assist with research, and discuss coding determinations as needed.
Analyze and interpret patient medical records, including behavioral health and other specialties, for FWA investigations as needed.
Compare medical records with claim submissions to determine the amount and nature of billable services as needed.
Determine the appropriateness of billing and reimbursement as needed.
Document findings for each claim line in a spreadsheet and summarize findings in written reports as needed.
Abstract CPT, HCPCS, Revenue, DRG, and ICD-9/ICD-10 codes from medical records as needed.
Maintain current knowledge of coding guidelines and relevant federal and state regulations.
Perform data analysis, lead generation, and data mining 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 company privacy and security standards and protect confidential information and protected health information.
Perform other duties as needed.