Medical Coder/ RN Job at Pyramid Consulting in Chicago

Job ID: 26-33958 Pay Range: $48.5/hour. Employee benefits include, but are not limited to, health insurance (medical, dental, vision), 401(k) plan, and paid sick leave (depending on work location).

Key Responsibilities: Analyze incoming third-party referrals, compliance tips, and external fraud allegations to identify specific billing patterns and suspect providers. Identify potential fraud, waste, abuse, and billing irregularities through thorough medical record reviews and claims analysis. Perform comprehensive clinical and technical reviews of high-dollar or complex medical records before claims are finalized for payment. Audit clinical documentation to ensure strict alignment with CPT, HCPCS, ICD-10-CM, ICD-10-PCS, and Official Coding Guidelines. Evaluate medical records against internal medical policies and prepare review summaries as needed. Collaborate closely with Medical Directors and prepare audit summaries to support referrals to Special Investigations Unit (SIU) or Compliance teams when warranted. Key Requirements and Technology Experience:5+ years combined experience in clinical auditing, medical coding, payment integrity, SIU investigations, or healthcare compliance. Active Nursing RN license. Core Coding Credentials: At least one active, nationally recognized coding certification from AAPC (CPC, COC, CIC, CPMA) or AHIMA (CCS, CCS-P, RHIT/RHIA).Experience in Behavioral Health coding and auditing. Knowledge of DSM-5 documentation requirements. Experience auditing mental health, substance use disorder, psychiatric facility, and behavioral health outpatient claims. Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions.