Of the $3.8T we spend on healthcare in the United States annually, about a third of it is estimated to be lost due to waste, fraud and abuse. Codoxo is the premier provider of artificial intelligence-driven solutions and services that help healthcare companies and agencies proactively detect and reduce risks from fraud, waste, and abuse and ensure payment integrity. Codoxo helps clients manage costs across network management, clinical care, provider coding and billing, payment integrity, and special investigation units. Our software-as-a service applications are built on our proven Forensic AI Engine, which uses patented AI-based technology to identify problems and suspicious behavior far faster and earlier than traditional techniques.

We are venture backed by some of the top investors in the country, with strong financials, and remain one of the fastest growing healthcare AI companies in the industry.

Key Responsibilities:

• Proactively identify instances of potential facility/institutional/outpatient fraud, waste, and abuse through data analysis using company system and tool
• Evaluate post-pay or pre-pay facility claims using standard principles and state-specific policies and regulations in order to identify incorrect coding, abuse and fraudulent billing practices, waste, overpayments, and processing errors of claims.
• Perform data analytics to identify fraud, waste or abuse in claims data
• Responsible for investigating, researching and analyzing software data in order to detect fraudulent, abusive or wasteful activities/practices.
• Assist engineering and data science teams with audit and FWA concepts, data mapping, and data definitions
• Use knowledge of facility claims coding, auditing, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant laws to find suspicious patterns in claims data and other sources
• Develop and maintain general knowledge of facility reimbursement policies and state and federal regulations related to facility fraud and abuse
• Communicate with customers regarding findings from company software and assist customers with navigating company software
• Work cooperatively and constructively with team members, including mentoring, training and assisting team members as required
• Perform additional duties and projects as assigned by management
• Maintain security and confidentiality of all protected health information encountered in performance of duties

Qualifications:

• Active CCS, CPC or Coding certification with facility claims audit and investigative experience
• 3+ years of experience working in a cost containment, payment integrity, fraud, audit, compliance or analytics role
• 3+ years of experience within health plan, facility, government pharmacy or other similar Industry role
• Knowledge of claims processing, billing and coding, facility contracting and reimbursement methodologies
• Knowledge of payment integrity audits for DRG, DRG clinical validation, Short Stay and Itemized Bill Reviews
• Data and analytics experience
• Thorough knowledge of medical terminology, medical records, health information management and medical coding, DRG methodologies, CPT/HCPCS coding guidelines, Physician Specialty guidelines reimbursement programs, claims adjudication processes, member contract benefits and regulatory agency policies (CMS/HCFA, DOI, State regulations), and provider billing systems and practices.
• Must possess a detailed knowledge of insurance operations and understand the impact of decisions on various areas of the organization.
• Experience working in a payer/healthplan claims system(s)
• High School Diploma /GED or higher
• Competency in Excel - creating/updating spreadsheets, pivot tables and formulas

Preferred Qualifications:

• Professional Certification as a COC (Certified Outpatient Coder)
• AHFI Certification
• Health Plan facility coding xperience
• Experience with issue resolution

Benefits for You

• Health, Dental, and Vision insurance with 100% employee premium coverage (Starts Day 1)
• Unlimited PTO
• Annual Professional Development stipend
• Annual home office stipend
• 401K Match (after 90 days)

We are an Equal Opportunity Employer:

Codoxo provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.This policy applies to all terms and conditions of employment.