Healthcare Coding Expert (certified professional coder)

Job description

Accountabilities Perform analytical activities supporting healthcare fraud, waste, and abuse prevention initiatives, including identifying potential referrals and investigative leads. Analyze medical claims data to identify trends, anomalies, patterns, and potential indicators of fraud, waste, or abuse. Review medical claims for accuracy, completeness, coding compliance, reimbursement appropriateness, and adherence to applicable insurance policies. Apply expertise in ICD-10, CPT, HCPCS, medical terminology, reimbursement methodologies, and healthcare coding guidelines to claims analysis. Research healthcare policies, coding standards, reimbursement criteria, and regulatory requirements to support investigations and referrals. Contribute to the development of analytical reports and communicate findings and outcomes to relevant stakeholders. Track and support outcome metrics associated with fraud, waste, and abuse referrals and leads shared with participating partners. Analyze healthcare claims data to support study referrals, investigative leads, provider background profiles, and potential collaboration opportunities. Respond to questions regarding analytical outputs from internal and external stakeholders, providing clear explanations and evidence-based conclusions. Participate in quality assurance activities to ensure deliverables meet regulatory requirements, healthcare policies, industry standards, and project expectations. Support program integrity activities, including audits, pre-payment and post-payment reviews, investigations, edits, and referrals. Maintain strict confidentiality and protect sensitive healthcare information in accordance with applicable privacy and security requirements. Provide coaching, guidance, and knowledge-sharing to less experienced professionals when needed. Manage complex analytical assignments independently while maintaining accuracy, deadlines, and organizational priorities. Requirements Bachelor’s degree or equivalent combination of education and relevant professional experience. 8+ years of experience in healthcare claims analysis or a closely related healthcare analytics discipline. Active Certified Professional Coder (CPC) certification through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) certification through the American Health Information Management Association (AHIMA). Extensive knowledge of medical terminology and healthcare coding systems, including ICD-10, CPT, and HCPCS. Demonstrated experience in healthcare program integrity and fraud, waste, and abuse activities, including audits, investigations, edits, pre-payment and post-payment reviews, and referrals. Strong understanding of insurance regulations, reimbursement methodologies, healthcare policies, and compliance requirements. Experience analyzing claims data and translating complex findings into actionable insights and recommendations. Strong written and verbal communication skills, including the ability to present findings and recommendations to management-level stakeholders. Advanced proficiency with Microsoft Office, particularly Excel and other analytical productivity tools. Experience with tools such as Tableau, Amazon WorkSpaces, Jira, and Confluence. Working knowledge of HIPAA privacy and security requirements. Strong decision-making, analytical, organizational, and problem-solving abilities. Demonstrated leadership qualities and the ability to work independently with minimal guidance. Highly detail-oriented, with the ability to prioritize multiple assignments and perform effectively under pressure. Strong interpersonal skills and the ability to establish productive relationships with stakeholders at different levels. High initiative, accountability, and follow-through when addressing complex problems. Ability to work effectively both independently and as part of multidisciplinary teams. Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) certification is strongly preferred. Benefits Competitive estimated salary range of $77,775–$105,225, with actual compensation determined by experience, geographic location, and applicable contractual considerations. Comprehensive medical insurance options, including plans with Health Savings Accounts. Dental and vision insurance options. 401(k) plan with company matching and flexible contribution options. Paid vacation, sick, and personal leave. Paid holidays, parental leave, military leave, bereavement leave, and jury-duty leave. Typically 15 days of paid leave per calendar year, plus 10 paid holidays, subject to applicable eligibility and proration rules. Paid family leave of up to 160 hours within a rolling 12-month period for eligible employees. Short- and long-term disability benefits. Life insurance and accidental death and dismemberment coverage. Personal accident, critical illness, and business travel and accident insurance options. Flexible work arrangements designed to support work-life balance. Full-time schedule of approximately 40 hours per week. Opportunity to contribute to high-impact healthcare program integrity and fraud prevention initiatives. Professional environment offering opportunities to collaborate with experienced healthcare analytics and coding professionals. Approximately 10–25% travel may be required. How Jobgether works: We use an AI-powered matching process to ensure your application is reviewed quickly, objectively, and fairly against the role's core requirements. Our system identifies the top-fitting candidates, and this shortlist is then shared directly with the hiring company. The final decision and next steps (interviews, assessments) are managed by their internal team. We appreciate your interest and wish you the best! Why Apply Through Jobgether? Data Privacy Notice: By submitting your application, you acknowledge that Jobgether will process your personal data to evaluate your candidacy and share relevant information with the hiring employer. This processing is based on legitimate interest and pre-contractual measures under applicable data protection laws (including GDPR). You may exercise your rights (access, rectification, erasure, objection) at any time. #LI-CL1 This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Healthcare Coding Expert (Certified Professional Coder) based in Canada. This role offers an opportunity to apply deep healthcare coding and claims expertise to initiatives focused on identifying and preventing fraud, waste, and abuse.You will analyze complex medical claims data, identify potential risks and patterns, and develop actionable leads and referrals.Working as part of a multidisciplinary healthcare analytics team, you will contribute to projects supporting program integrity and better use of healthcare resources.The position combines detailed claims analysis with policy research, investigative work, reporting, and quality assurance.You will collaborate with internal and external stakeholders and help translate analytical findings into meaningful outcomes.Your expertise in coding standards, reimbursement methodologies, and healthcare compliance will be central to maintaining accuracy and regulatory alignment.The role also provides opportunities to guide less experienced professionals and contribute to complex projects with significant public-sector impact.