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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. • 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) • 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. • Works independently; collaborates 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. Mental Requirements: • Communicating with others to exchange information. • Assessing the accuracy, neatness, and thoroughness of the work assigned. • Must have the ability to positively handle/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 be able to 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. Base compensation ranges from $68,000 to $88,000 per year. Specific offers are determined by various factors, such as experience, education, skills, certifications, and other business needs. Cotiviti offers team members a competitive benefits package to address a wide range of personal and family needs, including 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. For information about our benefits package, please refer to our Careers page. Date of posting: 7/21/2025 Applications are assessed on a rolling basis. We anticipate that the application window will close on 9/21/2025, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected. #senior #LI-JB1 #LI-Remote Apply tot his job
