Healthcare Fraud Shield

Detects fraud, waste, abuse in healthcare

SIU Clinical Investigator

Clinical Support & Patient AdministrationUpdated on Nov 13

Full-timeChesterfield, MO, USANo salary listedRemote

About the Job

Requirements

Knowledge of medical terminology.
Knowledge of coding, including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10.
Knowledge of specialty medical practices.
Ability to communicate effectively both verbally and in writing.
Strong listening skills.
Ability to meet defined performance and production goals.
Strong computer skills.
Certified Professional Coder (CPC) certification through AAPC is required.
A minimum of one year of coding and/or billing experience is required.
The role requires discretion and secure management of confidential and sensitive information.
The employee must comply with company privacy and security standards and may not use or disclose protected health information except as permitted or required by law.

Responsibilities

Work with the SIU team, including clinical reviewers, Certified Professional Coders, investigators, and analysts, by quality-checking work, assisting with research, and discussing coding determinations as needed.
Analyze and interpret patient medical records for fraud, waste, and abuse investigations.
Compare claim information to determine the amount and nature of billable services.
Determine the appropriateness of billing and reimbursement.
Document claim-line findings in a spreadsheet.
Summarize findings in a written report.
Abstract CPT, HCPCS, Revenue, DRG, and ICD-9/ICD-10 codes from medical records.
Maintain current knowledge of coding guidelines and relevant federal and state regulations.
Perform data analysis of client data.
Conduct aspects of fraud, waste, and abuse investigations.
Provide subject-matter expertise and Special Investigations Unit support to clients.

Healthcare Fraud Shield, a leader in healthcare fraud prevention and payment integrity solutions, is looking for a talented Clinical Coder/Fraud Investigator to join our team.

Work with SIU Team (Clinical Reviewers, CPCs, Investigators, Analysts-including performing quality check on work, assisting in research, discuss to make appropriate coding determinations as needed).
Analyze and interpret patient medical records pertaining to FWA investigations as needed.
Compare information submitted on the claims to determine the amount and nature of billable services as needed.
Determines appropriateness of billing and reimbursement as needed.
Documents findings for each claim line in a spreadsheet as needed.
Summarize findings in a written report as needed.
Abstracts CPT, HCPCS, Revenue Codes, DRG codes, and ICD-9/ICD-10 from medical records as needed.
Responsible for maintaining current knowledge of coding guidelines and relevant federal and/or state regulations as needed.
Perform data analysis of client data as needed.
Conduct various aspects of FWA investigations as needed.
Provide Subject Matter Expertise and SIU support to clients as needed.
Comply with Privacy and Security standards.
Understands and complies with all company Privacy and Security standards.
Employee may not use or disclose any protected health information, except as otherwise permitted, or required, by law.
Other duties as needed.

Knowledge of medical terminology.
Knowledge of coding including CPT, HCPCS, Revenue Codes, DRG Codes, and ICD-10.
Knowledge of specialty medical practices.
Must be detail-oriented.
Ability to communicate effectively both verbally and in writing.
Strong listening skills.
Independent.
Responsible.
Self-disciplined.
Ability to meet defined performance and production goals.
Strong computer skills.
This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.

Certificate/License:

Certified Professional Coder - (CPC®) through governing body AAPC.
Minimum of one year of coding and/or billing experience is required.

About the Company

Healthcare Fraud Shield

Detects fraud, waste, abuse in healthcare

Healthcare Fraud Shield provides fraud, waste, and abuse detection solutions for the healthcare industry through the FWAShield suite. The products include pre-payment and post-payment analysis that flag ineligible claims by linking proprietary data sources with analytics, plus features like real-time queries, complex reports, and automated case management. It differentiates itself by adapting quickly to client needs and offering scalable, data-driven tools combined with customization and expert claims analysis. Its goal is to reduce financial losses from improper payments and maximize ROI for healthcare providers, insurers, and other stakeholders.

Company size: 51-200
Company stage: Late Stage VC
Total funding: $50M
Headquarters: Chesterfield, MO
Founded: 2011

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