Data Mining Auditor- Payment Integrity

PLEASE NOTE BEFORE APPLYING: CODOXO IS NOT ABLE TO OFFER SPONSORSHIP OR ACCOMMODATE ANY CANDIDATES THAT ARE CURRENTLY BEING SPONSORED NOW OR IN THE FUTURE 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. Position Summary: The Data Mining Auditor performs medical claim audits to identify overpaid claims, through review of billing and coding policies, provider contract language, and State and Federal regulations. Audits include verification of claims data in our customer claims processing systems, and review of clinical and claims documents to make final determinations. This position requires a highly motivated problem solver with strong analytical ability, solid organizational skills, and medical auditing experience, to include an extensive background in claim adjudication processes and various reimbursement methodologies. Responsibilities may also include assisting with development of audit specifications and development of client deliverables. Key Responsibilities: Perform medical claim audits by reviewing customer claims data and charges, and/or medical records, to ensure compliance with CPT-4/HCPCS and ICD-10-CM coding guidelines and standards, as well as customer requirements and guidelines. Draft clear, defensible audit rationales and findings documentation suitable for client review, provider outreach, and downstream recovery or action workflows. Collaborate with internal analytics and AI teams to translate clinical, coding, and regulatory requirements into audit concepts, models and deterministic review logic. Maintain excellent quality, accuracy, and high productivity levels. Keep current on medical coding guidelines. Demonstrate efficient use of relevant software tools. Participate in departmental meetings, contribute to business development initiatives and office functions. Prioritize assignments and responsibilities to meet goals and deadlines. Qualifications: Active coding certification from either AAPC or AHIMA is required. SQL or Python experience is highly desirable but not required. 4+ years of work experience with a focus on healthcare provider billing and coding audits. Advanced knowledge of CPT-4, HCPCS, and ICD-10-CM coding systems, guidelines, and regulatory requirements. Knowledge of various reimbursement methodologies, to include MS-DRG, APR-DRG, OPPS, per diems, case rates, and RVU calculations. Knowledge of Medicare, Medicaid and Commercial reimbursement methodologies Knowledge of payer clams processing systems is desirable Comprehensive knowledge of industry standard rules, regulations, and guidelines as they apply to coverage, coding, and provider documentation, including but not limited to NCCI edits for PTP and MUE, global services, multiple procedure reductions, and COB. Proficient user in Microsoft Office Suite. Familiarity with JIRA, SharePoint, and AWS is also desirable. Excellent time management, organizational skills, and ability to prioritize work and meet deadlines. Exceptional verbal and written communication skills. Desire to work within a team environment Physical Requirements: Work is performed in an office environment (either in our office or work-from home) and requires the ability to work on a computer, operate standard office equipment, and work at a desk. Accessibility Notice: If you need reasonable accommodation for any part of the employment process due to a physical or mental disability, please send and email to [email protected] with the subject "Accommodation". Reasonable accommodation requests will be considered on a case-by-case basis. 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. Apply To This Job