Manager, Provider Scope Operations

Of the $3.8T we spend on healthcare in the United States annually, about a third of it is estimated to be lost due to waste, fraud and abuse. Codoxo is the premier provider of artificial intelligence-driven solutions and services that help healthcare companies and agencies proactively detect and reduce risks from fraud, waste, and abuse and ensure payment integrity. Codoxo helps clients manage costs across network management, clinical care, provider coding and billing, payment integrity, and special investigation units. Our software-as-a service applications are built on our proven Forensic AI Engine, which uses patented AI-based technology to identify problems and suspicious behavior far faster and earlier than traditional techniques. We are venture backed by some of the top investors in the country, with strong financials, and remain one of the fastest growing healthcare AI companies in the industry. Key Responsibilities: Lead and oversee the operations related to Provider Scope and provider education services Collaborate with product, security, engineering and data science teams, providing expert guidance on operational processes Lead the ideation for provider identification, themes and concepts Supervise the evaluation of post-pay or pre-pay claims, ensuring compliance with standard principles, state, federal and customer-specific policies and regulations to detect incorrect coding, abuse, fraudulent billing practices, waste, overpayments, and processing errors. Support and guide internal teams in the build, development, and implementation of Provider Scope operations Speak with providers in a professional manner; Lead and mentor teams responsible for speaking with providers Serve as a primary point of contact for Provider Scope customers regarding findings from company software, providing expert assistance and guidance to customers navigating company software. Maintain customer meeting schedules, agendas, notes and follow up items Maintain and execute on internal customer timelines for Provider Scope Lead, mentor, and train team members, fostering a cooperative and constructive team environment. Oversee additional duties and projects as assigned by senior management: Identification of potential facility/institutional/outpatient fraud, waste, and abuse through advanced data analysis using company systems and tools. Utilize deep knowledge of claims coding, auditing, fraud schemes, general areas of vulnerability, reimbursement methodologies, and relevant laws to detect suspicious patterns in claims data and other sources. Develop, implement, and maintain knowledge of facility reimbursement policies and state and federal regulations related to facility fraud and abuse. Impart knowledge for additional product and company initiatives Serve as a primary point of contact for assigned facility-based customers regarding all operations, providing expert assistance and guidance to customers navigating company software. Ensure the security and confidentiality of all protected health information encountered in the performance of duties. Qualifications: Active CCA, CCS, CPC or equivalent coding certification with extensive facility and professional claims audit and FWA experience. Minimum of 5 years of experience in cost containment, provider network/relations, payment integrity, fraud, audit, compliance, or analytics roles. At least 5 years of experience within health plans, facilities, government, vendor, or other similar industry roles. In-depth knowledge of claims processing, billing and coding, facility and professional contracting, and reimbursement methodologies. Proven expertise in data analytics. Experience with speaking with providers regarding coding behavior Comprehensive understanding of medical terminology, medical records, health information management, and medical coding, including DRG methodologies, CPT/HCPCS coding guidelines, Physician Specialty guidelines, reimbursement programs, claims adjudication processes, member contract benefits, and regulatory agency policies (CMS/HCFA, DOI, State regulations), and provider billing systems and practices. Thorough knowledge of health payer operations and the organizational impact of decision-making. Bachelor's degree or higher preferred. Advanced proficiency in Excel, including creating and updating spreadsheets, pivot tables, and formulas. Remote Work Requirements: To ensure reliable performance on the company-issued CODOXO laptop, employees working remotely must have a stable high-speed internet connection. Internet performance should be measured using a speed test conducted directly on the CODOXO laptop, not based solely on the internet plan purchased from the provider. Physical Requirements: Work is performed in an office environment (either in our office or work-from home) and requires the ability to work on a computer, operate standard office equipment, and work at a desk. Accessibility Notice: If you need reasonable accommodation for any part of the employment process due to a physical or mental disability, please send an email to [email protected] with the subject "Accommodation". Reasonable accommodation requests will be considered on a case-by-case basis. Benefits for You Health, Dental, and Vision insurance with 100% employee premium coverage (Starts Day 1) Unlimited PTO Annual Professional Development stipend Annual home office stipend 401K Match (after 90 days) We are an Equal Opportunity Employer: Codoxo provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment. Apply To This Job