Medical Review Auditor (Fraud Waste and Abuse)

About the role

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

Responsibilities

• Conduct audits of medical records and healthcare claims to assess the accuracy of medical coding and determine compliance with appropriate policies, procedures, and regulations.
• Prepare and submit detailed reports on audit findings, making recommendations to correct deficiencies and/or improve practices or processes.
• Conduct medical policy and other relevant research in support of review findings.
• Use knowledge of healthcare coding conventions, areas of vulnerability, reimbursement methodologies, and the ability to identify suspicious patterns in medical record documentation.
• Maintain current knowledge of federal, state, and individual payer policy and coding guidelines.
• Participate in special projects as required.

Requirements

• Bachelor’s Degree in a related discipline, or the equivalent combination of education, professional training, and work experience.
• Required credential: Certified Professional Coder (CPC, CCS, CCS-P).
• Preferred licenses: Licensed Practical Nurse (LPN) or Registered Nurse (RN).
• 2-5 years of related experience in auditing medical records.
• Computer proficiency in MS Office suite.
• Excellent verbal and written communication skills.
• Strong listening and observation skills.
• Attention to detail and a high level of accuracy.
• Effective organizational and prioritization skills with multi-tasking ability.
• Ability to conduct research in support of medical review determinations.
• Understanding of ICD, CPT, HCPCS, APC, DRG, Revenue Codes, NCDs, and federal and state guidelines (including CMS NCCI).
• Healthcare claims experience is helpful.
• Must work independently and collaborate well with peers and customers.
• Must have no adverse actions pending or taken against you by any State or Federal licensing board or program.

Mental Requirements

• Communicating with others to exchange information.
• Assessing the accuracy, neatness, and thoroughness of assigned work.
• Ability to positively handle and manage stress, such as high work volume and frequent change.

Physical Requirements and Working Conditions

• This is a work-at-home position (US only).
• Remaining in a stationary position, often standing or sitting for prolonged periods.
• Repeating motions that may include the wrists, hands, and/or fingers.
• Must provide a dedicated, secure work area.
• Access to high-speed internet is required (all other equipment will be provided).
• No adverse environmental conditions are expected.

Pay

Base compensation ranges from $70,000 to $91,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs.

Benefits

• Medical, dental, vision, disability, and life insurance coverage.
• 401(k) savings plans.
• Paid family leave.
• 9 paid holidays per year.
• 17-27 days of Paid Time Off (PTO) per year, depending on specific level and length of service with Cotiviti.