Nurse Clinician Managed Care (Certified Coder)

Job Title: Nurse Clinician Managed Care (Certified Coder)
Location: New York, NY 10004
Duration: 3+ months with very high possibility of extension

Shift Time: Monday – Friday, 9:00 AM – 5:00 PM (Hybrid)
 
Department: Special Investigations Unit (SIU)

Pay range: $50 - $55/hr. on W2
 
Remarks:
This is a hybrid position; candidates must have a valid New York State RN license.
Primary Source License Verification is required.
The successful candidate will support medical coding integrity and contribute to protecting the organization and its members from fraud and abuse.
 
Position Overview:

• We are committed to empowering New Yorkers by uniting communities through care. At our core, we believe healthcare is a right, not a privilege. If you are a compassionate professional with a collaborative spirit, join us and take pride in the work you do every day.
• We are currently seeking a Clinical Certified Coder to join our Special Investigations Unit (SIU). The coder will play a key role in detecting, preventing, and investigating suspected fraud, waste, and abuse (FWA) within healthcare billing and clinical documentation.

 
Key Responsibilities:

• Review medical records and healthcare claims to ensure clinical and coding accuracy and compliance with applicable standards and regulations.
• Conduct audits of high-risk claims and billing patterns to identify discrepancies, over-utilization, upcoding, and medically unnecessary services.
• Collaborate with SIU investigators and analysts to evaluate potential fraud or abuse cases.
• Create detailed medical review reports including clinical findings, supporting rationale, regulatory sources, and recommended actions.
• Determine whether claims should be denied or recouped and suggest appropriate mitigation strategies.
• Participate in provider calls and internal meetings to present audit findings and provide clinical/coding insights.
• Support documentation needs for audits, legal/compliance reviews, and regulatory responses.
• Maintain accurate records of investigations, including clinical notes, coding discrepancies, and communications.
• Stay up to date with changes in coding guidelines (ICD-10, CPT, HCPCS, etc.), fraud detection practices, and federal/state healthcare regulations.
• Complete special projects and audits as assigned by leadership.

 
Required Experience:

• Minimum 5 years of experience in healthcare fraud detection, auditing, or medical record review
• Strong clinical background with knowledge of medical terminology, billing practices, and healthcare regulations
• Proficient in coding standards: ICD-10, CPT, HCPCS, and AMA guidelines
• Strong analytical, research, and critical-thinking skills
• Excellent written and oral communication skills; able to communicate complex clinical findings clearly
• Proficient in Microsoft Office Suite (Word, Excel, Outlook, PowerPoint)
• Experience in Medicaid, Medicare, and/or Marketplace/Exchange plans – preferred

 
Required Qualifications:

• Registered Nurse (RN) – Must have active New York State license
• AAPC Certification – One or more of the following required:
• Certified Professional Coder (CPC)
• Certified Professional Medical Auditor (CPMA)
• Certified Coding Specialist (CCS)

• Bachelor’s Degree in Nursing, Medical Coding/Billing, Healthcare Administration, or related field