Provider Flag Management Senior Coding Analyst, Special Investigations Unit

is responsible for supporting the monitoring and ongoing management of provider flags across Commercial, Medicare, and Medicaid lines of business. This role partners with SIU Investigations, Coding, Prevention, Medical Directors, and operational teams to evaluate flag requests, analyze claim and inventory impacts, maintain governance processes, and support provider flag performance monitoring.

Additionally, the Flag Management Analyst collaborates with business partners to resolve complex flag-related issues, supports implementation of new flag strategies and enhancements, and contributes to continuous improvement initiatives that strengthen provider oversight and claim review operations. Responsibilities align with the organization's Flag Governance framework and provider flag management processes while promoting collaboration, accountability, and operational excellence.

Key Responsibilities:

• Review and analyze provider flag requests, including claim volume, financial impact, and inventory implications.
• Partner with investigation, coding, and CCR teams to construct recommendations and present findings to leadership and governance committees.
• Collaborate with SIU Investigators, Coding, Prevention, CCR, and Medical Directors via flag governance facilitation
• Monitor existing CCR, coding and administratively denied flags and evaluate performance metrics to support continuation, modification, or removal recommendations.
• Identify opportunities for mitigation strategies and operational improvements when flag placement is not approved or requires modification.

• 3+ years of experience in Behavioral Health and Medical Coding.
• Knowledge of Commercial, Medicare, and Medicaid claims processing and payment methodologies.
• Experience analyzing healthcare claims data and utilizing reporting tools to identify trends, risks, or operational opportunities.
• Demonstrated experience managing multiple priorities, projects, or workflows in a fast-paced environment.
• Experience with Microsoft Excel, reporting tools, and healthcare data analysis.
• Experience collaborating across multiple departments to drive processes, resolve issues, and achieve business objectives.
• Must be able to travel to provide testimony if needed.

Preferred Qualifications:

• Experience supporting provider flag management, provider review programs, claims editing, payment integrity, SIU, or fraud/waste/abuse initiatives.
• Experience working with provider data, NPI/TIN structures, claim inventory management, or case management systems.
• Familiarity with healthcare coding principles, medical record review processes, or claim adjudication workflows.
• Knowledge of healthcare regulations, compliance standards, and fraud prevention strategies.
• Experience facilitating governance reviews, stakeholder meetings, and presenting recommendations to senior leadership.
• Strong analytical, critical thinking, and problem-solving skills with the ability to make data-driven recommendations.
• Excellent written and verbal communication skills with experience presenting findings to business partners and leadership.
• Experience working in Microsoft PowerPoint.

• AAPC Certified Professional Coder Certification (CPC).
• GED or High School diploma.