Certified Professional Coder, Special Investigations Unit (Aetna SIU)

About the position The Certified Professional Coder (CPC) will perform medical claim reviews to ensure compliance with coding practices through a comprehensive record review for medical, behavioral, transportation and other healthcare providers. The CPC must have the ability to determine correct coding and appropriate documentation during the review of medical records. The CPC must also ensure that the state, federal and company requirements are met and recognize any concerning billing patterns or trends. Responsibilities • Conduct a comprehensive medical record review to ensure billing is consistent with medical record. • Provide detailed written summary of medical record review findings. • Articulate findings to investigators, Medicaid plan leadership, law enforcement, legal counsel, providers, state regulators, etc. • Review and discuss cases with Medical Directors to validate decisions. • Assist with investigative research related to coding questions, state and federal policies. • Identify potential billing errors, abuse, and fraud. • Identify opportunities for savings related to potential cases which may warrant a prepayment review. • Maintain appropriate records, files, documentation, etc. • Ability to travel for meetings and potential to testify. Requirements • AAPC Coding certification - Certified Professional Coder (CPC). • 3+ years of experience reviewing and analyzing medical records to determine appropriate CPT and HCPCS code assignments. • 3+ years' experience of ensuring coding is accurate and compliant with federal regulations, payer policies, and organizational guidelines. • Working experience with Microsoft Excel. • Strong attention to detail and ability to review and interpret data. Nice-to-haves • 2 years or more previous experience with medical record review within a healthcare insurance company. • Prior special investigation unit experience. • Excellent analytical skills. • Excellent communication skills. Benefits • Affordable medical plan options. • 401(k) plan (including matching company contributions). • Employee stock purchase plan. • No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching. • Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility. Apply tot his job Apply To this Job