Medix™

Compensation

Full Description

Clinical Coder – Special Investigations Unit Schedule: Full-Time | Monday–Friday, 9:00 AM–5:00 PM Work Setting: REMOTE (Must live in NY state) Join a mission-driven organization committed to empowering communities through equitable, accessible health care. We are looking for a Clinical Coder to join our Special Investigations Unit (SIU). In this key role, you will help prevent and detect fraud, waste, and abuse (FWA) in healthcare claims, ensuring integrity across the system. Key Responsibilities • Review medical records and claims to ensure accuracy and compliance with applicable coding regulations and internal policies. • Audit high-risk claims and billing patterns to detect FWA and enforce compliance. • Collaborate with SIU investigators to assess potentially fraudulent practices such as upcoding, over-utilization, or billing for unnecessary services. • Prepare detailed medical review reports, including findings, rationale, sources, and recommendations for corrective action. • Present findings to internal stakeholders and participate in provider calls to explain outcomes and review rationales. • Assist with documentation for audits, legal/compliance reviews, recoupments, and regulatory inquiries. • Maintain thorough case documentation, including coding discrepancies and provider communications. • Stay current on evolving coding standards, healthcare regulations, and fraud detection methodologies. • Support ad hoc audits and special projects as assigned. Required Qualifications • Registered Nurse (RN) – Required • AAPC Certification – Must hold one of the following: • Certified Professional Coder (CPC) • Certified Professional Medical Auditor (CPMA) • Certified Coding Specialist (CCS) • Bachelor's degree in Nursing, Medical Billing/Coding, Healthcare, or a related field • Experience in healthcare fraud detection, investigation, or auditing • In-depth knowledge of coding regulations including ICD-10, CPT, HCPCS, and AMA guidelines • Strong analytical and problem-solving skills with excellent attention to detail • Effective written and verbal communication skills • Ability to engage with medical providers, legal teams, compliance, and internal stakeholders Preferred Qualifications • Familiarity with Medicaid, Medicare, and Marketplace/Exchange environments • Strong skills in Microsoft Office (Excel, Word, PowerPoint, Outlook) • High integrity, professionalism, and customer-focused mindset