Medical Reviewer, Healthcare Fraud, Waste and Abuse

Overview

Join our dynamic team as a Medical Reviewer specializing in Healthcare Fraud, Waste, and Abuse detection. In this vital role, you will leverage your expertise in medical coding, billing, and healthcare documentation to identify and prevent fraudulent activities that compromise the integrity of healthcare systems. Your keen eye for detail and thorough understanding of medical records will contribute to safeguarding resources and ensuring compliance with industry regulations. This position offers an exciting opportunity to make a meaningful impact in the fight against healthcare fraud while working within a collaborative and innovative environment. Essential Duties and Responsibilities:

• Organize and prioritize assigned reviews to make payment determinations in accordance with coding guidelines and medical policies, utilizing expertise in CDT, CPT, ICD, DRG, REV, and HCPCS coding to identify and address potential healthcare fraud schemes.
• Perform reviews of (pre-payment or post-payment) medical records and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
• Conduct medical policy and other research relevant to allegations and healthcare claims, determining the accuracy of codes billed and compliance with appropriate policies, procedures, and regulations.
• Document and prepare well-articulated reports of medical review findings, highlighting key concerns, potential overpayments, and recommendations for payers/clients.
• Effectively communicate findings to internal teams/leadership and actively support client interactions under supervision.
• Participate in provider education calls to support medical review findings.
• Assist in legal proceedings, including testifying and providing evidentiary support for medical review outcomes.
• Analyze existing policies and processes to identify inefficiencies and propose actionable improvements.
• Keep up to date with relevant regulations and standards, including federal policies and coding guidelines.
• Actively engage and support all other projects assigned.
• Maintain confidentiality and discretion in all medical review/investigative activities.

Required Education / Licenses / Certifications:

• Certified Professional Coder (CPC) and/or Registered Nurse (RN) with no adverse actions pending or taken by any state/Federal program.

Experience:

• Minimum of 3 years of coding or clinical experience.
• Experience in healthcare fraud, waste, and abuse (FWA) prevention through medical claims review, auditing, or investigations is preferred.

Consideration will be given to candidates with any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. Knowledge, Skills & Abilities:

• Competency in healthcare coding systems (ICD, CPT, HCPCS, DRG, REV) and regulatory guidelines at federal/state levels.
• Excellent attention to detail with the ability to interpret complex medical information accurately
• Strong proficiency with MS Word, Excel, and PowerPoint
• The ability to conduct research in support of medical reviews and make determinations on claims with a high level of accuracy.
• Strong integrity, professionalism, and interpersonal skills.
• Effective written and oral communication.
• Ability to work independently and as part of a remote team.
• Attention to detail and basic problem-solving skills.

Join us in protecting the integrity of healthcare delivery by applying your expertise in medical review and coding. Be part of a dedicated team committed to transparency, accuracy, and excellence in healthcare compliance! Job Types: Full-time, Part-time Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Retirement plan
• Vision insurance

Application Question(s):

• Is your RN License a Compact License?
• Do you have any experience with fraud, waste and abuse (FWA)?
• What are your salary requirements (please provide a range)

Experience:

• Medical coding: 3 years (Required)

License/Certification:

• RN and or CPC (Required)

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