RN CODING SPECIALIST

RN needed for Major Insurance Provider to review medical record claims

Hybrid schedule    $55 / hr  ONSITE 2 days a Week LOWER MANHATTAN

AAPC Coding certification - Certified Professional Coder (CPC), Certified Professional Medical Auditor (CPMA) or Certified Coding Specialist (CCS) - Required

Registered Nurse (RN) – Required

Review medical records and healthcare claims to determine the accuracy and compliance of billed codes with appropriate regulations, standards, policies and procedures.

Conduct audits of high-risk claims and billing patterns to ensure adherence to healthcare regulation and MetroPlusHealth policy and detect potential FWA.

Collaborate with other SIU team members to evaluate suspected cases of fraudulent activities, such as over-utilization of services, upcoding, and billing for non-medically necessary services.

Create detailed reports with medical review findings that include research, rationale, sources and corrective action recommendations to the SIU Department. The reports will also validate whether audited claims should be denied, recouped and if other mitigation strategies are required.

Participate as needed on provider calls to discuss findings and rationale of medical review.

Present findings to leadership and other stakeholders to facilitate all FWA proceedings.

Assist in preparing documentation for audits, recoupments, compliance / legal reviews and regulatory inquiries.

Maintain thorough documentation of investigations, including clinical findings, coding discrepancies and all communication with healthcare providers and investigators.

Stay updated to changes to coding guidelines, healthcare regulations, and fraud detection methods to ensure compliance and effective investigations.