Job Description
HEALTHCARE Coding Subject Matter Expert At GDIT, people are our differentiator. As a Healthcare Coding Subject Matter Expert (SME) supporting the Centers for Medicare and Medicaid (CMS), you will be trusted to research healthcare fraud trends and draft supporting documenting for cross payer analytics for the Healthcare Fraud Prevention Partnership (HFPP) members (Partner) and the Trusted Third Party (TTP). You will be part of a 50-person team supporting the TTP which was established in 2012 to reduce fraud, waste and abuse in healthcare data. We are GDIT. The people supporting and securing some of the most complex government, defense, and intelligence projects across the country. We ensure today is safe and tomorrow is smarter. Our work has meaning and impact on the world around us, but also on us, and that’s important. GDIT is your place. You make it your own by embracing autonomy, seizing opportunity, and being trusted to deliver your best every day. We think. We act. We deliver. There is no challenge we can’t turn into opportunity. Our work depends on a Healthcare Coding SME joining our team to support CMS Trusted Third Party activities. Roles and Responsibilities • Reviews and analyzes medical claims to determine accuracy, completeness and compliance with insurance policies, coding guidelines and reimbursement criteria. • Verifies the accuracy of diagnosis and procedure codes in claims data, ensuring alignment with medical policies and industry coding standards. • Identify fraud, waste, and abuse schemes and conduct research and investigation of insurance policies, coding guidelines and reimbursement criteria • Participate in HFPP analytics development in cross-payer environments through creating supporting documents, presentations, and deliverables • Collaborates with Healthcare Fraud Prevention Partnership (HFPP) Partners to obtain additional information, clarification or documentation needed to review fraud, waste, and abuse schemes. • Participates in quality assurance initiatives to ensure deliverable adherence to regulatory requirements, medical and company policies and industry standards. • Authors analytic output for non-technical audience • Evaluates and responds to analytic output questions from internal and external parties. • May coach and provide guidance to less experienced professionals. Required Education and Experience • BA/BS or equivalent experience • 8+ years’ experience in health care claims analysis • 8+ years’ experience in fraud, waste, and abuse investigations • Certified Professional Coder (CPC) through the American Academy of Professional Coders (AAPC) or Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA) • Expertise in medical terminology and all healthcare coding (e.g., ICD-10, CPT, HCPCS) • Experience in program integrity and healthcare fraud, waste, and abuse activities, including edits, audits, pre-payment and post-payment review, investigations, referrals • Extensive knowledge of insurance regulations, reimbursement methodologies and healthcare compliance requirements. • Strong oral and written communication skills with the ability to present to management level staff. • Expert level knowledge of Microsoft Office suite. • Working knowledge of HIPAA privacy and security rules. Desired Qualifications • Certified Fraud Examiner (CFE) or Accredited Healthcare Fraud Investigator (AHFI) designation strongly desired. • Experience with Tableau, Amazon WorkSpaces, Jira, and Confluence. Soft Skills qualifications • Ability to communicate technical and non-technical language to technical and non-technical audiences • Ability to prioritize multiple tasks to meet established deadlines and satisfy internal and external customer demands • Strong decision-making skills and a demonstrated history of established leadership qualities as well as proven organizational skills. • Commitment to confidentiality, privacy, and professionalism. • Ability to independently follow through on problems. • Detail oriented and ability to prioritize multiple tasks and work under pressure. • Ability to work on complex projects with general direction and minimal guidance • Ability to build effective relationships, demonstrating strong interpersonal skills. • Exhibit high initiative to get things accomplished; high organizational ability to juggle multiple priorities. • Ability to perform well and achieve goals both in a team environment, with staff at all levels, and independently. Security Clearance Level • Must be able to obtain a public trust clearance Location: Remote GDIT IS YOUR PLACE • At GDIT, the mission is our purpose, and our people are at the center of everything we do. • Growth: AI-powered career tool that identifies career steps and learning opportunities • Support: An internal mobility team focused on helping you achieve your career goals • Rewards: Comprehensive benefits and wellness packages, 401K with company match, and competitive pay and paid time off • Flexibility: Full-flex work week to own your priorities at work and at home • Community: Award-winning culture of innovation and a military-friendly workplace #GDITFedHealthJobs Apply tot his job