Senior Coding Quality Analyst (CPC) – Special Investigations Unit (Aetna SIU)
Core
Perform medical claim reviews for the Special Investigations Unit to ensure compliance with coding practices and identify billing errors, abuse, or fraudulent activity.
Role type
Senior IC medical coding quality analyst (fraud investigation)
Builds
Medical, behavioral health, and transportation provider claims
Domain
Healthcare / Medical Coding / Fraud Investigation
Required skills
AAPC CPC certification, medical coding (CPT/HCPCS/ICD-10), quality review of coding decisions, fraud/waste/abuse detection, data analysis, Microsoft Excel/Word
Preferred skills
CPMA certification, analytical skills, attention to detail
Technologies
CPT, HCPCS, ICD-10, Microsoft Excel, Microsoft Word
Responsibilities
Conduct comprehensive quality reviews of completed medical coding reviews; Perform in-depth medical record reviews across various healthcare provider claims; Analyze data to identify potential billing errors, abuse, or fraudulent activity; Prepare detailed written summaries of findings; Independently research and apply state, CMS, and payer specific guidelines; Provide mentorship and training to coders; Maintain accurate documentation and tracking logs.
Seniority
Senior, hands-on IC