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The Certified Professional Coder (CPC) Manager will oversee a team of medical coders within the Special Investigations Unit (SIU) to ensure compliance with coding practices through comprehensive record reviews for medical, behavioral, transportation, and other healthcare providers. • Ensure staff provide detailed written summaries of medical record review findings and ensure the team articulates findings effectively to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, and state regulators.

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 (SIU) Manager

FULL_TIME

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.

YEAR

Metropolitan Jewish Health System

Fraud Investigator

[AW]-iCims

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 .

Baystate Health

Registered Nurse - HCC/RAF Coding Specialist

In terms of professional development, Everforth Apex hosts an on-demand training program, provides access to certification prep and a library of technical and leadership courses/books/seminars once you have 6+ months of tenure, and certification discounts and other perks to associations that include CompTIA and IIBA. Education: Must possess current knowledge of Healthcare/Coding as normally obtained through the completion of a bachelor's degree in healthcare administration or related field, or equivalent experience in a related field.

HOUR

StratAcuity Staffing Partners Inc

Risk Adjustment Audit Reviewer

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

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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)

This role is responsible for developing, delivering, and evaluating provider-focused coding and documentation education programs that promote accurate clinical documentation, compliant coding practices, and optimal charge capture. OneOncology is positioning community oncologists to drive the future of medical care through a patient-centric, physician-driven, and technology-powered model to help improve the lives of everyone living with cancer and other diseases.

OneOncology Inc

RCM Coding Education Specialist

This role evaluates coding accuracy, identifies documentation deficiencies, conducts audits, provides education to coding staff and providers, and supports revenue cycle integrity while minimizing compliance risk. The Medical Coding Auditor is responsible for keeping Sutherland coders in compliance by reviewing medical records and coding practices to ensure accurate assignment of ICD-10-CM, CPT, and HCPCS Level II codes in compliance with federal, state, payer, and organizational guidelines.

As a process transformation company, Sutherland rethinks and rebuilds processes for the digital age by combining the speed and insight of design thinking with the scale and accuracy of data analytics. We have been helping customers across industries from financial services to healthcare, achieve greater agility through transformed and automated customer experiences for over 30 years. 

Headquartered in Rochester, N.Y., Sutherland employs thousands of professionals spanning 19 countries around the world. To learn more, please visit us at www.sutherlandglobal.com.

Sutherland Global Services Inc

Lead - Healthcare - Coding Quality Auditor

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.

P1 Dental Partners

Medical Billing and Coding Specialist

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.

Special Investigation Unit Lead Review Analyst II (Aetna SIU)

Provides status, leads discussion of change requests, and organizes routine and ad-hoc meetings with Suspecting Governance, Working Group Committee and Clinical Actions leaders. Primary Responsibilities: Evaluates clinical and medical coding appropriateness of the suspecting engines with the goal of defining improvement needs and escalation to leadership.

divvyDOSE

Lead Clinical Nurse Analyst - San Antonio, | Antonio, |

IRecruitee

Responsibilities: Responsible for daily operations pertaining to Risk Adjustment including but not limited to: medical record reviews to report ICD-10-CM diagnosis codes for ACA and MA lines of business, potential Centers of Medicare & Medicaid Services (CMS), Health and Human Services (HHS) audits and medical record retrieval efforts. Pay Transparency: The base pay for this role is: $82,717 - $108,566 per year You are also eligible for employee benefits, participation in Oscar's unlimited vacation program and annual performance bonuses.

Oscar Health Insurance

Risk Adjustment Auditor

The team interacts regularly with other areas within Payment Integrity to provide consulting on complex claims processes as well as provides adjustment support to the other areas including the vendor team and the clinical teams. Every claim paying over a certain amount is reviewed by this team utilizing multiple lenses including processor quality and the assignment of errors to individual claims processors as well as claims payment accuracy.

Highmark provides millions of people with the security of quality health insurance
Our history of helping families and companies with their health insurance needs dates to the 1930s, when our predecessor companies were established to help Pennsylvania's residents pay for health care.
Highmark was created in 1996 by the consolidation of two Pennsylvania licensees of the Blue Cross and Blue Shield Association — Pennsylvania Blue Shield (now Highmark Blue Shield) and Blue Cross of Western Pennsylvania (now Highmark Blue Cross Blue Shield). We are now one of the largest health insurers in the United States.
Highmark's officers and board of directors set the company's strategic direction and corporate policies. They are guided by our mission, vision and values.

Highmark Inc

Manager Payment Integrity

Revenue Integrity Specialist (Professional Billing) Position Overview Serves as a Charge Generation Tracker (CGT) and regulatory resource to ensure compliance with coding and billing guidelines. Acts as a primary resource for providers and staff, supporting revenue integrity, charge capture, and coding accuracy.

Top Prospect Group founders and management team offer more than 75 years of combined experience in Information Technology, Creative & Marketing, and Finance & Accounting staffing and solutions. Our fundamental goal is to build successful relationships resulting in accurate job and prospect representations. We meet with those we work with face-to-face to garner a better understanding of candidate or client requirements. By leveraging our experience and market insight, we are able to provide a more consistent recruitment process. Motivated by a partnership philosophy, our staff possesses a deep understanding of how to forge mutually beneficial long-term relationships. We believe in what we do and continuously strive for excellence.

Top Prospect Group LLC

Revenue Integrity Specialist

HaleyMarketing

We require a drug-free workplace and require team members to comply with the MMR, Varicella, Tdap, and Influenza vaccine requirement if in an on-site or hybrid workplace category. From workshops that develop cultural intelligence, to our inclusion resource groups for people to find community and empowerment at work, we are dedicated to ongoing resources that advance our values of diversity, equity, and inclusion in all that we do.

Corewell Health

Audit Compliance Manager

Our commitment to the University of Nebraska Athletic Department (Husker Team Physicians), area high schools and recreational athletes shows our motivation to minimize an athlete’s downtime so they can compete to the best of their ability. Essential Duties: (This list may not include all the duties assigned) Reviews CPT and ICD-10 codes from providers for office charges for accuracy.

Nebraska Orthopaedic Center

Charge Entry Specialist FT (In Office)

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.

Gainwell Technologies LLC

Associate Manager, Clinical Claim Review- Remote

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

Employee must be 18 years of age or older; Certified Professional Coder (CPC), Certified Coding Specialist – Physician-based (CCS-P), or equivalent credential required; Certified Professional Medical Auditor (CPMA) credential a plus; Firm understanding of medical terminology; Strong understanding of the laws regarding compliance; Ability to work independently and as part of a team; Excellent written and verbal communication skills; Excellent computer skills, including Microsoft Office applications; Two years’ experience working in a medical facility preferred; primary care physician (PCP) practice a plus; Two years’ medical coding experience preferred; Two years’ medical auditing experience preferred; Ability to prioritize and multitask; Ability to sit for up to 8 hours at a time. • Paid Annual Leave, Volunteer Time Off Pay, Bereavement Leave, Emergency Leave Bank.

Patient First History Since opening our first medical center in 1981, Patient First's vision remains the same: making access to quality medical care as convenient and cost-effective as possible. To achieve this objective, we have adopted and continue to embrace many innovative operating systems and practices. All Patient First medical centers are open every day of the year from 8 am to 10 pm - including weekends and holidays. Patients can come at times that best fit their schedules and when urgent medical attention is needed on days as well as at times when other facilities are closed. No appointments are necessary. Patients can walk into a Patient First center and receive prompt attention upon arrival. Patients who wish to see a particular physician or physician assistant can call ahead or click here to explore the dates and times when that person will be seeing patients. X-rays, lab tests, and pre ion drugs are available on-site to save time and reduce the need for extra trips. These innovations, along with sophisticated, automated registration and treatment systems and our commitment to an excellent medical staff and quality of care have been widely accepted, allowing Patient First to expand considerably over the years. Patient First now offers both primary and urgent care services and participates in most insurance plans. We also provide a broad range of Occupational Health services. There are currently 41 Patient First centers: 9 in Greater Richmond; 8 in Greater Hampton Roads, Tidewater, and the Peninsula; 14 in Greater Baltimore; 5 in Greater DC; 2 in Eastern Pennsylvania; and 3 in Central Pennsylvania. Expansion plans include building additional centers in all these areas in addition to other localities and states.

Patient First

Coding & Reimbursement Analyst

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.

Training Manager Jobs in Summit, KY

Special Investigation Unit (SIU) Manager CVS Health

Fraud Investigator Metropolitan Jewish Health System

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Risk Adjustment Audit Reviewer StratAcuity Staffing Partners Inc

Revenue Cycle Manager Pacific Health Group

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

RCM Coding Education Specialist OneOncology Inc

Lead - Healthcare - Coding Quality Auditor Sutherland Global Services Inc

Medical Billing and Coding Specialist P1 Dental Partners

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

Lead Clinical Nurse Analyst - San Antonio, | Antonio, | divvyDOSE

Risk Adjustment Auditor Oscar Health Insurance

Manager Payment Integrity Highmark Inc

Revenue Integrity Specialist Top Prospect Group LLC

Audit Compliance Manager Corewell Health

Charge Entry Specialist FT (In Office) Nebraska Orthopaedic Center

Associate Manager, Clinical Claim Review- Remote Gainwell Technologies LLC

Supervisor, RCSS University of Utah

Coding & Reimbursement Analyst Patient First

Coding Auditor/Educator- Laboratory Carle Foundation Hospital

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