Medical Coder Job at W3R Consulting in Springfield
w3r consultingSpringfield (IL)
Medical Coder Job at W3R Consulting in Springfield
Posted 11 days ago
w3r consultingSpringfield (IL)
Health Information Technologists and Medical RegistrarsAll Other Miscellaneous Ambulatory Health Care Services
SENIORITY
Senior
About the role
Description:
Investigates complex healthcare claims flagged by third-party referrals, tips, or external allegations prior to payment. This role combines advanced clinical coding expertise (ICD-10, CPT, HCPCS) with investigative scrutiny. The auditor reviews medical records to verify that documented services match the billed codes, adhere to medical necessity guidelines, and comply with state, federal, and contractual coding regulations.
Key responsibilities: Allegation Triaging & Investigation:
- Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns, suspect providers, or unbundled services.
- Identify potential fraud, waste, abuse, billing irregularities, and patterns of non-compliance through medical record review and claims analysis.
- Pre-Payment Clinical Review:
- Perform comprehensive clinical and technical reviews of high-dollar or highly complex medical records before a claim is finalized for payment.
- Coding & Documentation Validation:
- Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines.
- Medical Necessity Assessment:
- Evaluate medical records against internal medical policies, prepare review summary as needed and work closely with Medical Directors
- Prepare audit summaries and support referrals to Special Investigations Unit (SIU), Provider Performance, or Compliance teams when warranted.
- Required Qualifications & Education:
Education: Nursing RN, active license
Core Coding Credentials: Must hold at least one active, nationally recognized coding certification:
AAPC:
Certified Professional Coder (CPC), Certified Outpatient Coder (COC), Certified Inpatient Coder (CIC) or Certified Professional Medical Auditor (CPMA).AHIMA: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician-based (CCS-P), or Registered Health Information Technician/Administrator (RHIT/RHIA).
Experience:
5 years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, utilization management, or healthcare compliance, or related healthcare reimbursement functions, including medical record review and claims auditing. Technical Expertise: Demonstrated proficiency in CPT, HCPCS Level II, ICD-10-CM, and medical record documentation review. Working knowledge of CMS reimbursement methodology, National Correct Coding Initiative (NCCI) edits, and applicable federal and state regulations. Prefer: Behavioral Health coding and auditing experience. Knowledge of DSM-5 documentation requirements. Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims.
Before you apply
Applying takes about a minute. These four things decide how fast it moves after that.
Your profile is current
It's what we read first. Occupations, seniority and locations matter more than a long history.
Two examples you can talk through
Not a portfolio — just two pieces of work where you can explain the decisions and what you'd change.
A number in mind
What you're on now and what would make you move. We negotiate better when we know both.
Your notice period
Employers plan around it, and it's the question that stalls offers most often.
Once you apply, someone reads it and calls you before anything reaches the employer — usually within two working days.