Medical Review Auditor (Fraud Waste and Abuse)

Overview

As a Medical Reviewer, you will be auditing medical records to evaluate the accuracy of medical coding and health plan policies for our Fraud, Waste & Abuse clients.

Responsibilities

• Conducts audit of medical records and healthcare claims assessing the accuracy of medical coding and determining compliance with appropriate policies, procedures, and regulations.
• Prepares and submits detailed reports on audit findings making recommendations to correct deficiencies and/or practice or process improvements.
• Counsels and educates clients on fraud prevention and compliance.
• Conducts medical policy and other relevant research in support of review findings.
• Uses knowledge of healthcare coding conventions, areas of vulnerability, reimbursement methodologies, and the ability to identify suspicious patterns in medical record documentation.
• Maintains current knowledge of federal, state, and individual payer policy and coding guidelines.
• Participates in special projects as required.

Qualifications

• Education & Certifications: Bachelor’s Degree in a related discipline, or the equivalent combination of education, professional training, and work experience. Preferred licenses: Licensed Practical Nurse (LPN), Registered Nurse (RN). Required Credential: Certified Professional Coder (CPC, CCS, CCS-P).
• Experience: 2-5 years of related experience in auditing medical records.
• Computer Proficiency: Computer proficiency in MS Office suite.
• Communication Skills: Excellent verbal and written communication skills. Strong listening and observation skills.
• Attention to Detail: Attention to detail and a high level of accuracy.
• Organizational Skills: Effective organizational and prioritization skills with multi-tasking ability.
• Research Skills: Ability to conduct research in support of medical review determinations.
• Knowledge: Understanding of ICD, CPT, HCPCS, APC, DRG, Revenue Codes, NCDs, and federal and state guidelines (including CMS NCCI).

Benefits

• Base compensation ranges from $70,000 to $91,000 per year.
• Benefits package includes medical, dental, vision, disability, and life insurance coverage, 401(k) savings plans, paid family leave, 9 paid holidays per year, and 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.