UNKNOWN

FEED

As a key contributor to the SIU lead development process, this role evaluates provider, member, pharmacy, and ancillary healthcare billing patterns for signs of fraud, waste, abuse, and other anomalies. The Analyst II uses internal claims data, analytical tools, business rule results, and industry intelligence to assess potential FWA concerns and determine whether they warrant formal investigation.

CVS Health offers a world of promising job opportunities across a diverse range of careers in everything from corporate and pharmacy roles to retails positions. No matter where you work at CVS Health, your unique skills, talents and abilities are welcome and valued. We recognize and reward greatness and want our employees to know their work is making a difference in the lives of millions. Join us today. Together we can continue making innovative, high-quality health and pharmacy services safe, affordable and accessible – for all.

CVS Health

Special Investigation Unit Lead Review Analyst II (Aetna SIU)

The individual must demonstrate knowledge of the principles of life span growth and development and the ability to assess data regarding the patient''s status and provide care as described in the department''s policies and procedures manual. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission.

The state’s oldest and largest institution of higher education, the University of Utah is the flagship university of the state. The University offers more than 100 undergraduate and 90 graduate degree programs to more than 31,000 students (23,500 undergraduate and 7,500 graduate). The University is noted for its high research profile, its diversity of ideas and people, its stunningly beautiful setting and the warmth, friendliness, and collegiality of its faculty staff, and students. Imagine yourself working in a collaborative, creative, respectful environment where everyone’s contribution is needed and appreciated – University of Utah!

University of Utah

Supervisor, RCSS

Gainwell Technologies defines "wages" and "wage rates" to include "all forms of pay, including, but not limited to, salary, overtime pay, bonuses, stock, stock options, profit sharing and bonus plans, life insurance, vacation and holiday pay, cleaning or gasoline allowances, hotel accommodations, reimbursement for travel expenses, and benefits. Active, Unrestricted RN license from the United States and in the primary home residency, active compact multistate unrestricted RN license as defined by the Nurse Licensure Compact (NLC) or Certified Professional Coder (CPC), Certified Coding Specialist (CCS), or Certified Professional Medical Auditor (CPMA) required.

YEAR

Gainwell Technologies LLC

Associate Manager, Clinical Claim Review- Remote

This includes oversight of the day-to-day workflow processes, staff scheduling, productivity monitoring, staff coaching and training, exercising judgement in hiring and corrective/disciplinary action, and including supervisory of direct reports for the functional area within the coding department. The health system operates 18 hospitals and 130 outpatient locations with nearly 14,000 team members, including 1,300 employed physicians and advanced practice clinicians.

Aspirus Inc

SUPERVISOR- CODING - CODING

The Revenue Cycle Manager ensures services are appropriately supported by documentation, claims and encounters are submitted accurately and timely, outstanding revenue is actively managed, reimbursement discrepancies are identified and resolved, and Revenue Cycle activities comply with payer, contractual, regulatory, and organizational requirements. Through programs such as Enhanced Care Management (ECM), Community Supports (CS), Community Health Worker (CHW) services, Behavioral Health, and other community-based healthcare programs, PHG works collaboratively with health plans, providers, community organizations, and other partners to support whole-person care.

Pacific Health Group

Revenue Cycle Manager

Workable

Supports manager by interpreting and analyzing billing data to identify and monitor performance and established benchmarks for the departmentMaintains knowledge of current and required coding regulations and assures team members are updated as regulations change. Certifications: Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA); Certified Professional Coder (CPC) - American Academy of Professional Coders (AAPC), Education:, Work Experience: Coding.

HOUR

Carle Foundation Hospital

Coding Auditor/Educator- Laboratory

RN Clinician is responsible for reviewing provider post-payment inquiries and claim reconsiderations to ensure accurate coding in accordance with established coding guidelines, CMS guidelines, Health Plan Coding Payment Policy, and Claim Payment Policy. Ensures compliance with health plan policy and other regulatory agencies such as Bureau of Insurance (BOI), National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services (CMS), and Virginia Department of Medical Assistance Services (DMAS).

Sentara Hospitals

Clinical Claims Reviewer/ RN

FULL_TIME

This individual will analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities, then work directly with claims administrators on behalf of our ASO clients to secure claim adjustments, recoveries, and repricing. We are seeking an experienced Senior Claims Analyst with deep expertise in hospital claims adjudication, stop loss reporting, high-cost/catastrophic claims, and DRG (Diagnosis-Related Group) reimbursement methodology.

SmartLight Analytics

Senior Clinical Large Claims Specialist

partner JazzHR

ADAPTED_NOW

Actively pursues effective and efficient operations of their respective areasin accordance withHealth New England’s Values, its Code ofConductand the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct. + Usingmedical record and clinical qualityexpertise, performs HEDIS clinical abstraction in both directelectronic medical record (EMR) and physical medical records to auditprovider compliance with HEDIStechnical specifications.

Baystate Health

Quality Improvement Specialist II

Validate whether the FWA (Fraud, Waste & Abuse) detection approach surfaces real, actionable fraud/waste/abuse signals and produce substantiated findings to support FWA product development. Comfortable working with partial or imperfect data sets, including sample extracts rather than fully developed production systems.

HireTalent

Senior SIU Analyst - FWA Detection

jobdiva

This position works closely with physicians, advanced practice providers, coding and billing personnel, revenue cycle leadership, compliance officers, operational leaders, and other healthcare stakeholders to promote compliant documentation, coding, billing, and reimbursement practices. Experience performing documentation, coding, and billing audits in a healthcare system, academic medical center, physician practice, consulting organization, or related setting preferred.

PACT MSO, LLC

Medical Coding Auditor

The investigator analyzes claims, encounter, enrollment, medical record, and provider data; conducts interviews, field investigations, and on-site audits, when necessary; prepares detailed investigative reports; and collaborates with compliance, legal, operational stakeholders, regulatory agencies, and law enforcement. Responsibilities: The SIU Fraud Investigator is responsible for identifying, investigating, and resolving allegations and indicators of fraud, waste, and abuse (FWA) involving providers, vendors, members, and other parties participating in Elderplan’s product lines.

Metropolitan Jewish Health System

Fraud Investigator

[AW]-iCims

Deliver individual and group education sessions, primarily through virtual platforms, for providers, coding teams, and leadership on risk adjustment, HCC documentation, ICD-10-CM guidelines, clinical documentation requirements, compliant query practices, CMS expectations, and value-based care initiatives. Build trusted working relationships with network practice coders, coding leaders, providers, regional clinical leaders, and operational partners to understand workflows, identify needs, and provide practical support.

Strive Health, LLC

Risk Adjustment Documentation & Coding Educator

The HCC/RAF Coding Specialist serves as a key resource supporting providers and clinical teams by ensuring patient conditions are accurately reflected in the medical record in accordance with CMS Hierarchical Condition Category (HCC) and MassHealth DxCG guidelines. Our network includes Baystate Medical Center, Baystate Children's Hospital, Baystate Noble Hospital, Baystate Franklin Medical Center, Baystate Wing Hospital, Baystate Medical Practices, and Baystate Home Health & Hospice .

Registered Nurse - HCC/RAF Coding Specialist

Applicable professional certification through American Health Information Management Association (AHIMA); Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), or Certified Coding Associate (CCA) or America Academy of Professional Coders (AAPC); Certified Professional Coder Hospital (CPC H), Certified Outpatient Coder - Hospital (COC-H) required. Bachelor's degree in health information management (HIM), business or other healthcare related field or equivalent combination of education/experience (two years' experience in health information management equals one year of education) required.

Nebraska Medicine

HIM Coding Lead - Revenue Integrity

The purpose of this position is to oversee the data collection, management, analysis, and reporting functions needed to support regulatory, quality, and strategic healthcare services for the Community Wellness Department and WISEWOMAN Women's Health Program. Oversee the preparation and submission of all required, regulatory, and quality improvement data reports for various external and internal stakeholders such as CDC, HHS, NIH, IHS, HRSA, as well as the senior management team.

Southeast Alaska Regional Health Consortium

Community Wellness Data Program Manager

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Under the guidance of the Manager of GAU, collaborates with the designated GAU Reporting Analyst and GAU Manager to generate reports for including but not limited to CMS, EOHHS, OHIC audits, and participates in the compiling of all grievance, appeal, and complaint records selected for on-site audits. Builds effective and successful interdepartmental relationships with all areas of the company and utilizes good communication and customer service skills in responding to internal and external inquiries about the grievance, appeal and complaint process while being able to respond quickly regarding the status.

Neighborhood's employees come from a diverse background but all are committed to creating a more equitable health care system. Our array of experiences allows us to have a broad perspective and great creativity in facing whatever challenges arise. Unlike many other health insurance companies, we have nearly 30 nurses and social workers on staff. This structure speaks to our focus on active and compassionate care management for our members; we know that people who are alienated from the health care system require additional advocacy, outreach and support. 

Neighborhood offers an exceptional compensation package to employees. We annually review base salaries/benefits and adjust as appropriate.

Neighborhood Health Plan of Rhode Island

Grievance and Appeals Coordinator (44913)

Assist management with oversight of augmented staff by tracking performance, escalating issues, etcServe as a key resource in facilitating the gathering of business and technical requirements in addition to test cases for all configuration changes. Work with various business areas at different levels within the organization to translate business requirements into technical specifications documents and also act as liaison to translate technical questions and processes into a format the business can understand.

Senior Configuration Management Analyst (45017)

Senior Claims Analyst- Hospital Bill Review

As a remote Medical Billing and Coding Specialist, you will be responsible for accurately assigning appropriate medical codes to patient records, ensuring timely reimbursement from insurance companies, and maintaining compliance with all relevant regulations and guidelines. To be successful in this role, candidates must possess the following qualifications: - Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) certification.

Certified Professional Coder Jobs in the United States

Special Investigation Unit Lead Review Analyst II (Aetna SIU) CVS Health

Supervisor, RCSS University of Utah

Associate Manager, Clinical Claim Review- Remote Gainwell Technologies LLC

SUPERVISOR- CODING - CODING Aspirus Inc

Revenue Cycle Manager Pacific Health Group

Coding Auditor/Educator- Laboratory Carle Foundation Hospital

Clinical Claims Reviewer/ RN Sentara Hospitals

Senior Clinical Large Claims Specialist SmartLight Analytics

Quality Improvement Specialist II Baystate Health

Senior SIU Analyst - FWA Detection HireTalent

Medical Coding Auditor PACT MSO, LLC

Fraud Investigator Metropolitan Jewish Health System

Risk Adjustment Documentation & Coding Educator Strive Health, LLC

Registered Nurse - HCC/RAF Coding Specialist Baystate Health

HIM Coding Lead - Revenue Integrity Nebraska Medicine

Community Wellness Data Program Manager Southeast Alaska Regional Health Consortium

Grievance and Appeals Coordinator (44913) Neighborhood Health Plan of Rhode Island

Senior Configuration Management Analyst (45017) Neighborhood Health Plan of Rhode Island

Senior Claims Analyst- Hospital Bill Review SmartLight Analytics

Medical Billing and Coding Specialist P1 Dental Partners

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