Special Investigations Unit Clinical Certified Coder

Position Overview

Metro Plus Health  seeks a Clinical Certified Coder to support the Special Investigations Unit in detecting, preventing, and investigating suspected fraud, waste, and abuse. The role reports to the Director of the Special Investigations Unit.

• Review medical records and claims to determine accuracy and compliance with regulations.
• Conduct high‑risk claim audits to detect potential fraud, waste, and abuse.
• Collaborate with the SIU team to evaluate suspected fraudulent activities such as over‑utilization, upcoding, and non‑medically necessary services.
• Create detailed reports with findings, rationale, sources, and corrective action recommendations.
• Assist in provider calls to discuss findings and rationale.
• Present findings to leadership and stakeholders to facilitate FWA proceedings.
• Prepare documentation for audits, recoupments, compliance/legal reviews, and regulatory inquiries.
• Maintain thorough documentation of investigations, including findings, coding discrepancies, and communication with providers and investigators.
• Stay updated on coding guidelines, healthcare regulations, and fraud detection methods.
• Complete special projects and audits as required.

• At least 5 years of experience in healthcare fraud detection, investigation, or auditing.
• In‑depth knowledge and experience of coding regulations including ICD‑10, CPT, HCPCS, AMA, etc.
• AAPC coding certification
  - Certified Professional Coder (CPC) or Certified Professional Medical Auditor (CPMA) or Certified Coding Specialist (CCS).
• Bachelor’s degree in Nursing, Medical Billing/Medical Coding, Healthcare, or related field.
• Preferred experience in Medicaid, Medicare, and Marketplace/Exchange.

• AAPC coding certification
  - Certified Professional Coder (CPC) or Certified Professional Medical Auditor (CPMA) or Certified Coding Specialist (CCS).
• Valid New York State license and current registration to practice as a Registered Professional Nurse (RN) issued by the New York State Education Department (NYSED).

• Integrity and Trust
• Customer Focus
• Excellent Microsoft Office Suite skills
• Strong communication skills to interact with providers, medical management, legal teams, and compliance departments.
• Strong analytical, research, and problem‑solving aptitude with attention to detail and accuracy.