Do you want to help make healthcare more effective and affordable for everyone? That’s our mission at Codoxo. The U.S. spends more on healthcare than any other country in the world, but not all of the $3.8 trillion goes to real patient care. A significant portion, up to 10% or $380 billion, is lost to fraud, waste, and abuse.

Codoxo’s patented artificial intelligence technology helps healthcare companies and agencies identify and act quickly to control costs. Codoxo now has six AI-powered applications that help every department across health insurance payers proactively bring down costs and reduce fraud, waste, and abuse – so more dollars to toward patient care.


Primary 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 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

 

Required Qualifications:


  • Active CCA, 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
  • 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.
  • 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 experience
  • Experience with issue resolution