Healthcare Coding Expert (certified professional coder)

Accountabilities

• Perform analytical activities supporting healthcare fraud, waste, and abuse prevention initiatives, including identifying potential referrals and investigative leads.
• Analyze medical claims data to identify trends, anomalies, patterns, and potential indicators of fraud, waste, or abuse.
• Review medical claims for accuracy, completeness, coding compliance, reimbursement appropriateness, and adherence to applicable insurance policies.
• Apply expertise in ICD-10, CPT, HCPCS, medical terminology, reimbursement methodologies, and healthcare coding guidelines to claims analysis.
• Research healthcare policies, coding standards, reimbursement criteria, and regulatory requirements to support investigations and referrals.
• Contribute to the development of analytical reports and communicate findings and outcomes to relevant stakeholders.
• Track and support outcome metrics associated with fraud, waste, and abuse referrals and leads shared with participating partners.
• Analyze healthcare claims data to support study referrals, investigative leads, provider background profiles, and potential collaboration opportunities.
• Respond to questions regarding analytical outputs from internal and external stakeholders, providing clear explanations and evidence-based conclusions.
• Participate in quality assurance activities to ensure deliverables meet regulatory requirements, healthcare policies, industry standards, and project expectations.
• Support program integrity activities, including audits, pre-payment and post-payment reviews, investigations, edits, and referrals.
• Maintain strict confidentiality and protect sensitive healthcare information in accordance with applicable privacy and security requirements.
• Provide coaching, guidance, and knowledge-sharing to less experienced professionals when needed.
• Manage complex analytical assignments independently while maintaining accuracy, deadlines, and organizational priorities.

Requirements

• Bachelor’s degree or equivalent combination of education and relevant professional experience.
• 8+ years of experience in healthcare claims analysis or a closely related healthcare analytics discipline.
• Active Certified Professional Coder (CPC) certification through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) certification through the American Health Information Management Association (AHIMA).
• Extensive knowledge of medical terminology and healthcare coding systems, including ICD-10, CPT, and HCPCS.
• Demonstrated experience in healthcare program integrity and fraud, waste, and abuse activities, including audits, investigations, edits, pre-payment and post-payment reviews, and referrals.
• Strong understanding of insurance regulations, reimbursement methodologies, healthcare policies, and compliance requirements.
• Experience analyzing claims data and translating complex findings into actionable insights and recommendations.
• Strong written and verbal communication skills, including the ability to present findings and recommendations to management-level stakeholders.
• Advanced proficiency with Microsoft Office, particularly Excel and other analytical productivity tools.
• Experience with tools such as Tableau, Amazon WorkSpaces, Jira, and Confluence.
• Working knowledge of HIPAA privacy and security requirements.
• Strong decision-making, analytical, organizational, and problem-solving abilities.
• Demonstrated leadership qualities and the ability to work independently with minimal guidance.
• Highly detail-oriented, with the ability to prioritize multiple assignments and perform effectively under pressure.
• Strong interpersonal skills and the ability to establish productive relationships with stakeholders at different levels.
• High initiative, accountability, and follow-through when addressing complex problems.
• Ability to work effectively both independently and as part of multidisciplinary teams.
• Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification is strongly preferred.

Benefits

• Competitive estimated salary range of $77,775–$105,225, with actual compensation determined by experience, geographic location, and applicable contractual considerations.
• Comprehensive medical insurance options, including plans with Health Savings Accounts.
• Dental and vision insurance options.
• 401(k) plan with company matching and flexible contribution options.
• Paid vacation, sick, and personal leave.
• Paid holidays, parental leave, military leave, bereavement leave, and jury-duty leave.
• Typically 15 days of paid leave per calendar year, plus 10 paid holidays, subject to applicable eligibility and proration rules.
• Paid family leave of up to 160 hours within a rolling 12-month period for eligible employees.
• Short- and long-term disability benefits.
• Life insurance and accidental death and dismemberment coverage.
• Personal accident, critical illness, and business travel and accident insurance options.
• Flexible work arrangements designed to support work-life balance.
• Full-time schedule of approximately 40 hours per week.
• Opportunity to contribute to high-impact healthcare program integrity and fraud prevention initiatives.
• Professional environment offering opportunities to collaborate with experienced healthcare analytics and coding professionals.
• Approximately 10–25% travel may be required.