Job Description

Key Responsibilities :

1. Forensic Review : 1. Conduct comprehensive forensic examinations of medical records, bills, and associated documents to identify inaccuracies, misrepresentations, or instances of fraud. 2. Evaluate and interpret CPT, ICD, HCPCS, and other relevant coding systems to pinpoint discrepancies or inaccuracies. 3. Understand and navigate EHR systems and billing software. Assist with internal or external audits regarding billing and documentation.
2. Legal Testimony : 1. Serve as an expert witness in legal proceedings, providing clear, accurate, and authoritative testimony on medical coding, billing, Medicare allowances, UCR (Usual, Customary, and Reasonable) rates, EHR platforms and healthcare compliance matters. 2. Prepare comprehensive reports and documentation to support legal findings.
3. Documentation & Reporting: 1. Document findings clearly and concisely, generating reports detailing discrepancies, overcharges, or suspected fraud. 2. Collaborate with legal and compliance teams, providing them with detailed evidence and data-backed insight for potential legal proceedings.
4. Compliance & Best Practices: 1. Stay updated on the latest medical coding and billing regulations, ensuring all analyses align with current standards and best practices. 2. Advise medical and administrative teams on compliance requirements and potential areas of risk.
5. Collaboration & Consultation: 1. Work closely with healthcare providers, insurance companies, and legal entities to provide expertise on medical billing and coding matters, UCR rates, proper documentation and methodology. 2. Serve as a consultant to payer sources and attorneys, offering guidance on best practices and potential areas of improvement.
6. Continued Education : 1. Attend workshops, conferences, and training sessions to stay current on the latest trends and developments in the forensic medical billing and coding field.
   1. Maintain relevant certifications and pursue additional qualifications as necessary.

Qualifications

Required Qualifications :

• 5 or more years of experience in medical billing and coding, with a focus on forensic analysis and insurance claims analysis.
• 5 or more years’ experience with the End-To-End Revenue Cycle Management process
• 5 or more years’ experience in medical record documentation review.
• Experience with complex claims analysis.
• Exceptional attention to detail and analytical skills.
• In-depth understanding of electronic health record functions and reporting capabilities.
• Experience with large data sets, metadata, and its analysis.
• In-depth understanding of healthcare billing processes, insurance claims, industry standards.
• In-depth understanding of correct coding application and regulatory guidelines.
• Certification in Medical Coding, such as CPC (Certified Professional Coder) or CCS (Certified Coding Specialist), BCSC (Billing coding Specialist Certification), or CMRS (Certified Medical Reimbursement Specialist (CMRS).

Additional Information

Preferred Qualifications :

• History of expert testifying experience.
• Batchelor’s degree or higher in business, or similar
• Familiarity with legal processes and protocols related to healthcare fraud.
• Strong written and verbal communication skills, with the ability to convey complex information clearly.
• Proficiency in using medical billing software and related technologies.
• Additional Medical Certification(s) such as FMC (Forensic Medical Coding), RHIA (Registered Health Information Administrator), CPMA (Certified Professional Medical Auditor), CHDA (Certified Health Data Analyst), Certified Professional Compliance Officer (CPCO), Certified Documentation Expert Inpatient (CDEI), Certified Documentation Integrity Practitioner (CDIP), Revenue Cycle Management Specialist (RCMS)