E/M & Multispecialty Medical Coder

Role Summary:

Review patient medical records based on review request from FIPR claims review team to identify incorrectly coded services (CPTs)/diagnoses (ICDs), Modifiers, DRGs, APCs which are not coded according to the coding guidelines laid down by the apex organizations like AMA, CMS (Medicare/Medicaid), or other recognized bodies/associations and the policies/guidelines laid down by payors for specific services.

This department is responsible for developing and maintaining an anti-fraud program which includes development and delivery of training and filing of Fraud Plans and Reports. The incumbent is responsible for conducting coding audits to identify alleged fraud, waste and abuse perpetrated by providers, members, facilities, pharmacies, groups and/or employees of the organizations and Subsidiaries based on their qualified areas. The incumbent is responsible for interviews which might include providers and members and may be conducted onsite or offsite. The incumbent is also responsible for the field investigative work necessary to complete a review of a special project, potential fraud, waste, and abuse case, conducting the initial investigations and coordinating the recovery/savings of money related to fraud, waste, and abuse. The incumbent must be able to testify in a court of law, prepare cases for referral to various federal, state, and local law enforcement entities and work with those agencies through closure of the case. Conduct audits for proactive and investigative purposes to comply with internal audit and regulatory requirements.

Essential Responsibilities

Provides advisory support as needed to internal and external law enforcement and regulatory agencies, Credentialing or Medical Review Committee.

Required

Must Have:

Good to Have: