Experienced Associate, Healthcare Forensics Coder

Experienced Associate, Healthcare Forensics

The Experienced Associate, Healthcare Forensics role is a highly analytical and detail-oriented individual responsible for identifying, analyzing, and resolving payment inaccuracies across healthcare claims as it relates to reimbursement disputes, fraud, waste, and abuse investigation, regulatory compliance, and litigation. The ideal candidate will bring a strong understanding of healthcare reimbursement methodologies, claims data, and regulatory frameworks. The Experienced Associate, Healthcare Forensics demonstrates an investigative mindset with problem solving skills and the ability to think critically about data to deliver high-quality work product for clients.

• Provides investigation and analysis to a variety of clients, including outside counsel, regulators, and companies involved in litigation, investigation, dispute, regulatory, and compliance matters
• Contributes to forensic engagements related to medical coding and billing, revenue cycle, payment integrity, the False Claims Act, the Stark Law, the Anti-Kickback Statute, and other matters
• Analyzes healthcare claims data to identify improper payments, billing errors, and potential fraud, waste, or abuse
• Develops and implements strategies to improve payment accuracy and mitigate over payments
• Collaborates with cross-functional teams to validate findings and recommend corrective actions
• Interprets payer policies, provider contracts, and regulatory guidelines to assess claim appropriateness
• Prepares and present detailed reports and recommendations to clients and internal stakeholders
• Supports the design and enhancement of payment integrity tools, algorithms, and audit methodologies
• Stays current on industry trends, CMS regulations, and emerging payment models
• Develops working relationships with internal and external stakeholders and communicates effectively
• Assists with the preparation of high-quality deliverables to ensure client satisfaction
• Acts with professionalism and integrity when working with confidential and sensitive information
• Maintains a proactive and logical approach to information gathering, combining complex ideas and clear and effective information presentation
• Identifies and researches new trends, tools, and understands the data analytics marketplace while working on client engagements
• Assists with developing documents, procedures, and solutions on non-billable practice development initiatives
• Other duties as required

Education:

High School Diploma or equivalent, required

Bachelor's degree in Healthcare Administration, Public Health, or Business, preferred

Experience:

Three (3) years of experience in healthcare consulting, revenue cycle, claims auditing, or payment integrity, required

Experience with healthcare reimbursement (Medicare, Medicaid, Commercial), coding (ICD-10, CPT, HCPCS), and claims processing, preferred

Experience in the following areas, preferred:

Forensic Analytics Compliance Analytics Artificial Intelligence Fraud Analytics

License/

Certifications:

Active credential in one (1) or more of the following, required:
Nationally recognized coding credential (e.g. CPC, CCS, RHIA, RHIA) and/or Certified in Healthcare Compliance (CHC)

Software:

Proficiency in data analysis tools (e.g., Excel, SQL, SAS, Tableau), preferred

Prior experience with Electronic Health Record software (e.g., EPIC, Cerner, Athena, etc.), preferred

Coding/DRG software, preferred

Other Knowledge, Skills & Abilities:

Ability to work with a high degree of professionalism and autonomy

Excellent verbal and written communication skills

Ability to communicate complex information in a clear and concise manner

Excellent communication, problem-solving, and project…