Certified Professional Coder, Special Investigations Unit (Aetna SIU)
Core
Perform medical claim reviews and audits for the Special Investigations Unit to ensure coding compliance, identify billing errors/fraud, and validate documentation against state/federal guidelines.
Role type
Senior IC medical coding auditor (special investigations)
Builds
Compliance audits and investigative reports for medical, behavioral, and transportation healthcare providers
Domain
Healthcare compliance and fraud investigation
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Medical coding (CPT/HCPCS/ICD-10), claim auditing, regulatory research (CMS/state guidelines), data analysis, Microsoft Excel/Word
Preferred skills
Behavioral health coding, prior auditing experience, analytical skills
Technologies
CPT, HCPCS, ICD-10, CMS 1500, UB04, Microsoft Excel, Microsoft Word
Responsibilities
Conduct comprehensive medical record audits to verify billed codes match documentation; Identify potential billing errors, abuse, and fraud; Articulate findings to investigators, legal counsel, and regulators; Research and apply state or CMS guidelines with minimal support; Review cases with Medical Directors to validate decisions; Maintain up-to-date knowledge of coding compliance changes.
