Clinical/Medical coder

Medical Coding Investigation Consultant

Job Summary

We are looking for a skilled and detail-oriented Prepay Coding Investigation Consultant to support healthcare payment integrity and fraud investigation processes. The role involves reviewing prepay claims, analyzing medical records, validating coding accuracy, and identifying potential healthcare fraud, waste, or abuse patterns.

The ideal candidate should possess strong expertise in CPT/ICD coding, clinical documentation review, and healthcare claims analysis, along with the ability to collaborate effectively with cross-functional stakeholders and clients.

This position requires strong analytical skills, attention to detail, and the ability to work independently while managing multiple priorities in a fast-paced healthcare environment.

Key Responsibilities

Day-to-Day Responsibilities

• Review prepay claims along with corresponding medical records to determine payment accuracy and coding compliance
• Analyze applicable coding policies, CPT guidelines, ICD standards, and healthcare contracts relevant to clinical review
• Investigate potential coding discrepancies, fraud, waste, and abuse patterns involving healthcare providers
• Participate in client and regulatory meetings related to coding investigations and payment integrity reviews
• Collaborate with providers, legal teams, advocates, and internal stakeholders to support issue resolution and provider communication
• Perform additional analytical and operational projects as assigned by business leadership or clients
• Monitor claim inventory regularly to ensure adherence to turnaround times and performance metrics
• Provide coding guidance and mentorship to team members on complex coding scenarios and investigations
• Support continuous process improvement initiatives related to claims review, coding investigations, and operational efficiency
• Maintain compliance with regulatory standards, internal policies, and quality requirements

Required Qualifications

• Graduate of a minimum 4-year Allied Medical Health program
• Certified Professional Coder (CPC) certification is mandatory
• Minimum 1+ years of clinical and/or medical coding experience in hospital, surgical, or clinical settings
• Minimum 1+ years of experience in a BPO or healthcare operations environment
• Strong knowledge of CPT and ICD coding standards
• Proficiency in PC-based applications and healthcare systems
• Strong analytical thinking, problem-solving, and investigation skills
• Ability to work independently with minimal supervision

Preferred Qualifications

• Candidates with Allied Medical Health backgrounds such as:
• Registered Nurse (RN)
• Physiotherapist
• Radiologic Technologist
• Pharmacist
• Experience in healthcare insurance billing and coding processes
• Strong organizational and multitasking abilities
• Ability to prioritize workload effectively in a fast-paced environment
• Excellent verbal and written communication skills
• Strong collaboration and stakeholder management capabilities
• Experience working in team-oriented environments

Key Skills

• CPT & ICD Coding
• Medical Record Review
• Healthcare Claims Analysis
• Payment Integrity
• Fraud, Waste & Abuse Investigation
• Coding Compliance
• Clinical Documentation Review
• Healthcare Operations
• Analytical & Problem-Solving Skills
• Stakeholder Coordination
• Regulatory Compliance
• Communication & Presentation Skills