Medical Review Auditor – Fraud Waste and Abuse
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Job Description
Medical Review Auditor auditing medical records and healthcare claims for Cotiviti’s Fraud, Waste & Abuse clients. Evaluating coding accuracy, policy compliance, and suspicious documentation patterns.
Responsibilities:
- Audit medical records and healthcare claims to assess medical coding accuracy and compliance with policies, procedures, and regulations
- Prepare and submit detailed reports on audit findings
- Make recommendations to correct deficiencies and improve practices or processes
- Conduct medical policy and relevant research to support review findings
- Apply knowledge of healthcare coding conventions, vulnerabilities, reimbursement methodologies, and suspicious documentation patterns
- 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 equivalent combination of education, professional training, and work experience
- Required credential: Certified Professional Coder (CPC, CCS, CCS-P)
- Preferred licenses: Licensed Practical Nurse (LPN) and 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 helpful
- Ability to work independently and collaborate well with peers and customers
- Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program
- Ability to positively handle/manage stress, including high work volume and frequent change
- Must be able to provide a dedicated, secure work area
- Access to high-speed internet is required
Benefits:
- Medical insurance coverage
- Dental insurance coverage
- Vision insurance coverage
- Disability insurance coverage
- Life insurance coverage
- 401(k) savings plan
- Paid family leave
- 9 paid holidays per year
- 17-27 days of Paid Time Off (PTO) per year, depending on level and length of service
- Work-at-home arrangement
- Dedicated, secure work area
- High-speed internet access required; all other equipment will be provided
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