Note: The job is a remote job and is open to candidates in USA. GDIT is a global technology and professional services company delivering technology solutions and mission services to government, defense, and intelligence organizations. The Healthcare Coding Expert will support CMS and the Healthcare Fraud Prevention Partnership by analyzing healthcare claims, identifying fraud, waste, and abuse, developing analytic reports, and generating referrals and leads. The role also includes quality assurance, research and investigation, stakeholder support, and guidance of less experienced professionals.
Responsibilities
- Performs analytical tasks in support of HFPP program, including identifying fraud, waste, and abuse referrals and leads from HFPP Analytics
- Collaborate on the development of HFPP analytic reports
- Drive outcome metrics related to fraud, waste, and abuse referrals and leads shared with Partners
- May perform business development activities including analyzing health claims data, generating study referrals and leads, developing provider background profiles, and identifying opportunities for Partner collaboration meetings
- Reviews and analyzes medical claims to determine accuracy, completeness and compliance with insurance policies, coding guidelines and reimbursement criteria
- Identify fraud, waste, and abuse schemes and conduct research and investigation of insurance policies, coding guidelines and reimbursement criteria
- Participates in quality assurance initiatives to ensure deliverable adherence to regulatory requirements, medical and company policies and industry standards
- Evaluates and responds to analytic output questions from internal and external parties
- May coach and provide guidance to less experienced professionals
Skills
- Claims Data, Data Analysis, Microsoft Excel, Policy Analysis, Strategic Objectives
- 8 + years of related experience
- No
- Bachelors degree or equivalent year of work experience
- 8+ years' experience in healthcare claims analysis
- Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)
- Expertise in medical terminology and all healthcare coding (e.g., ICD-10, CPT, HCPCS)
- Experience in program integrity and healthcare fraud, waste, and abuse activities, including edits, audits, pre-payment and post-payment review, investigations, referrals
- Extensive knowledge of insurance regulations, reimbursement methodologies and healthcare compliance requirements
- Strong oral and written communication skills with the ability to present to management level staff
- Expert level knowledge of Microsoft Office suite
- Experience with Tableau, Amazon WorkSpaces, Jira, and Confluence
- Working knowledge of HIPAA privacy and security rules
- Strong decision-making skills and a demonstrated history of established leadership qualities as well as proven organizational skills
- Commitment to confidentiality, privacy, and professionalism
- Ability to independently follow through on problems
- Detail oriented and ability to prioritize multiple tasks and work under pressure
- Ability to work on complex projects with general direction and minimal guidance
- Ability to build effective relationships, demonstrating strong interpersonal skills
- Exhibit high initiative to get things accomplished; high organizational ability to juggle multiple priorities
- Ability to perform well and achieve goals both in a team environment, with staff at all levels, and independently
- 10-25%
- Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation strongly desired
Benefits
- Medical plan options, some with Health Savings Accounts
- Dental plan options
- Vision plan
- 401(k) plan with the ability to contribute both pre- and post-tax dollars up to IRS annual limits and receive a company match
- Full flex work weeks where possible
- Paid time off plans, including vacation, sick and personal time, holidays, paid parental, military, bereavement and jury duty leave
- 15 days of paid leave per calendar year for new employees, prorated based on date of hire
- 10 paid holidays per year, prorated based on date of hire
- Up to 160 hours of paid family leave in a rolling 12-month period for eligible employees
- Short- and long-term disability benefits
- Life insurance
- Accidental death and dismemberment insurance
- Personal accident insurance
- Critical illness insurance
- Business travel and accident insurance
- Remote work
Company Overview