Medical Coder

Clinical Investigation

• Investigate healthcare claims to detect potential fraud, abuse, billing errors, and inappropriate claim submissions.
• Examine medical records, clinical documentation, and claim information to confirm coding correctness and reimbursement eligibility.
• Assess patient medical history and supporting documentation to verify claim validity.
• When needed, monitor and investigate high-value or complex claims.

Medical Coding Review

• Verify CPT, ICD, HCPCS, diagnosis, and procedure codes for coding accuracy.
• Use coding guidelines and reimbursement policies during claim investigations.
• Ensure adherence to coding standards and applicable regulatory requirements.
• Spot coding inconsistencies and suggest appropriate resolutions.

Claims Investigation & Resolution

• Investigate, recover, and resolve healthcare claims across commercial and government health plans.
• Coordinate claim recovery and reimbursement activities where applicable.
• Contribute to claim adjudication through detailed clinical and coding analysis.
• Record investigation findings and keep complete, accurate case documentation.

Compliance & Quality

• Ensure compliance with healthcare regulations, reimbursement policies, and contractual obligations.
• Follow applicable state and federal healthcare requirements.
• Adhere to defined quality standards and investigation protocols.
• Maintain audit readiness by ensuring accurate documentation and reporting.

Collaboration & Stakeholder Support

• Partner with claims, coding, quality, and clinical teams to resolve investigation cases.
• Provide support and guidance on coding-related issues as needed.
• Assist with reporting, special projects, and continuous improvement initiatives.
• Coordinate work activities and share knowledge with team members as required.

Documentation & Reporting

• Maintain comprehensive investigation records and all supporting documentation.
• Prepare investigation summaries and case reports.
• Ensure investigation outcomes are documented accurately and on time.
• Track case status and maintain required productivity and quality metrics.

Required Qualifications

Education

• Any Graduate.

Preferred qualifications:

• BHMS
• BAMS
• BUMS
• BPT
• MPT
• B.Sc. Nursing or BDS with minimum 1 year of corporate healthcare experience.

Certification

• AAPC Certified Professional Coder (CPC) – Mandatory
• Only CPC certification will be considered.

Experience

• Minimum 1 year of experience in Medical Coding or Clinical Investigation.
• Experience in specialty coding such as:
• Evaluation & Management (E&M)
• Surgery
• Anesthesia
• Multi-specialty coding
• Experience beyond HCC coding is preferred.

Preferred Skills

• US Healthcare knowledge.
• Claims processing experience.
• Health Insurance and Managed Care experience.
• Medical records review.
• Clinical documentation analysis.
• Healthcare reimbursement guidelines.
• Fraud, Waste & Abuse (FWA) investigations.
• Strong analytical and problem-solving skills.
• Excellent attention to detail and quality orientation.

Key Competencies

• Clinical Investigation
• Medical Coding (CPC)
• CPT, ICD & HCPCS Coding
• Claims Investigation
• Claims Processing
• Medical Record Review
• US Healthcare
• Health Insurance
• Managed Care
• Compliance & Regulatory Guidelines
• Fraud, Waste & Abuse (FWA)
• Reimbursement Policies
• Quality Assurance
• Documentation & Reporting
• Analytical Thinking
• Problem Solving
• Attention to Detail
• Cross-functional Collaboration