Certified Coder - Fraud, Waste & Abuse (FWA) Job at Summa Health in Cleveland

Certified Coder, Special Investigations Unit Investigator SummaCare – 1200 E Market St, Akron, OH Full-Time / 40 Hours / Days Hybrid / Remote Code with Integrity. Detect with Precision. Join Us as a Certified FWA Coder! Are you a certified coding professional with a sharp eye for detail and a passion for protecting healthcare integrity with experience reviewing medical records? Step into a high-impact role where your expertise helps uncover fraud, prevent waste, and ensure compliance across the healthcare system. We’re looking for a Fraud, Waste, and Abuse (FWA) Certified Coder to join our Special Investigations Unit and play a critical role in safeguarding resources and promoting ethical billing practices. This position collaborates with investigators, clinical and compliance staff, and regulatory agencies. Summary Performs review of medical claims to ensure compliance with industry standard coding practices and plan payment policies through a comprehensive medical record evaluation for all provider types. Determines correct coding and appropriate documentation required while ensuring state, federal and company policies are met. Makes recommendations to Medical Directors, Compliance, Internal Audit and the Fraud, Waste and Abuse (FWA) Committee for investigations and provider communication. Maintains knowledge of current schemes and ensures the SIU processes and procedures reflect industry norms. Formal Education Required Bachelor’s Degree, or equivalent combination of education and experience. Experience & Training Required Three (3) years of health insurance or provider office experience to include: clinical review of medical records, and appropriate claims coding Three (3) years’ experience of ensuring coding is accurate and compliant with federal regulations, payer policies, and organizational guidelines. Active AAPC Coding certification - Certified Professional Coder (CPC). Accredited Healthcare Fraud Investigator (AHFI) certification preferred. LSS Yellow Belt Certified preferred. Essential Functions Conducts comprehensive medical record reviews to ensure billing is consistent with the information contained in the medical record. Maintains a working knowledge of coding rules and industry coding guidelines. Provides detailed written summary of medical record review findings. Articulates findings to investigators, plan leadership, law enforcement, legal counsel, providers, state regulators, etc. Reviews and discusses cases with Medical Directors to validate decisions. Assist with investigative research related to coding questions, and state and federal policies. Makes recommendations for additional claim edits. Identifies potential billing errors and provides suggestions for provider education and/or plan payment policies. Identifies opportunities for savings related to potential cases resulting in a prepayment review. Maintains appropriate records, files, documentation, etc. Able to travel for meetings and to testify in legal hearings. Other Skills, Competencies and Qualifications: Demonstrate intermediate proficiency in MS Office, Project, and database management. Maintain excellent working knowledge of process improvement techniques, methodologies and principles applying these in the normal course of operations. Demonstrate excellent analytical and problem-solving skills. Effectively conduct statistical analyses and accurately work with large amounts of data. Ability to apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions. Ability to organize and manage time to accurately complete tasks within designated time frames in fast paced environment. Maintain current knowledge of and comply with regulatory and company policy and procedures. Level of Physical Demands: Sit for prolonged periods of time. Bend, stoop, and stretch. Lift up to 20 pounds. Manual dexterity to operate computer, phone, and standard office machines. Benefits Basic Life and Accidental Death & Dismemberment (AD&D) Supplemental Life and AD&D Dependent Life Insurance Short-Term and Long-Term Disability Accident Insurance, Hospital Indemnity, and Critical Illness Retirement Savings Plan Flexible Spending Accounts – Healthcare and Dependent Care Employee Assistance Program (EAP) Identity Theft Protection Pet Insurance Education Assistance Daily Pay $28.10/hr - $42.15/hr Equal Opportunity Employer/Veterans/Disabled As a regional, provider-owned health plan, SummaCare values the relationship between the members and their doctors. SummaCare is a part of Summa Health, an integrated healthcare delivery system that includes Summa Health System hospitals, its community-based health centers, dedicated clinicians and SummaCare. Based in Akron, Ohio, SummaCare provides Medicare Advantage, individual and family and commercial insurance plans. SummaCare has one of the highest rated Medicare Advantage plans in the state of Ohio, with a 4.5 out of 5-Star rating for 2025 by the Centers for Medicare and Medicaid Services (CMS). Known for its excellent customer service and personalized attention to members, SummaCare is committed to building lasting relationships. Employees can expect competitive pay and benefits. #J-18808-Ljbffr