Coder, Special Investigations Unit

Coder, Special Investigations Unit

Location: Akron United States

Hybrid

Job Description:

Certified Coder, Special Investigations Unit (SIU)

SummaCare - 1200 E Market St, Akron, OH

Full-Time / 40 hours / Days

• Hybrid or Remote

Join a mission‑driven health plan where precision and expertise protect both members and resources-we're seeking a certified coder who can identify discrepancies others miss, analyze coding patterns with accuracy, and turn complex clinical data into clear, actionable insights; if you bring deep knowledge of coding standards, a sharp analytical mindset, and a passion for ensuring integrity in healthcare claims, this is your opportunity to make a meaningful impact and strengthen the quality of care delivery.

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.

1. Formal Education Required:

a. Bachelor's Degree, or equivalent combination of education and experience.

2. Experience & Training Required:

a. Three (3) years of health insurance or provider office experience to include: clinical review of medical records, and appropriate claims coding

b. Three (3) years' experience of ensuring coding is accurate and compliant with federal regulations, payer policies, and organizational guidelines.

c. Active AAPC Coding certification - Certified Professional Coder (CPC).

d. Accredited Healthcare Fraud Investigator (AHFI) certification preferred.

e. LSS Yellow Belt Certified preferred.

Essential Functions:

1) Conducts comprehensive medical record reviews to ensure billing is consistent with the information contained in the medical record.

2) Maintains a working knowledge of coding rules and industry coding guidelines.

3) Provides detailed written summary of medical record review findings.

4) Articulates findings to investigators, plan leadership, law enforcement, legal counsel, providers, state regulators, etc.

5) Reviews and discuss cases with Medical Directors to validate decisions.

6) Assist with investigative research related to coding questions, and state and federal policies. Makes recommendations for additional claim edits.

7) Identifies potential billing errors and provides suggestions for provider education and/or plan payment policies.

8) Identifies opportunities for savings related to potential cases resulting in a prepayment review.

9) Maintains appropriate records, files, documentation, etc.

10) Able to travel for meetings and to testify in legal hearings.

3. Other Skills, Competencies and Qualifications:

a. Demonstrate intermediate proficiency in MS Office, Project, and database management.

b. Maintain excellent working knowledge of process improvement techniques, methodologies and principles applying these in the normal course of operations.

c. Demonstrate excellent analytical and problem-solving skills.

d. Effectively conduct statistical analyses and accurately work with large amounts of data.

e. Ability to apply principles of logical thinking to define problems, collect data, establish facts, and draw valid conclusions.

f. Ability to organize and manage time to accurately complete tasks within designated time frames in fast paced environment.

g. Maintain current knowledge of and comply with regulatory and company policy and procedures.

4. Level of Physical Demands:

a. Sit for prolonged periods of time.

b. Bend, stoop, and stretch.

c. Lift up to 20 pounds.

d. Manual dexterity to operate computer, phone, and standard office machines.

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 2026 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.

$28.10/hr - $42.15/hr

The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.

Summa Health offers a competitive and comprehensive benefits program to include medical, dental, vision, life, paid time off as well as many other 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