Job Description |
The Medical Review auditor is responsible for reviewing medical documentation in support of FWA investigations to ensure appropriate coding and policy guidelines have been followed. This candidate may also supervise subordinate staff in ensuring customer expectations are met.
Conduct reviews of medical records and associated pre-pay or post-pay claims in the course of fraud, waste and abuse investigations and other program integrity initiatives.
- Use knowledge of healthcare coding conventions, fraud schemes, known areas of vulnerability, reimbursement methodologies, and relevant laws to help identify suspicious patterns in claims data, provider enrollment data, and other sources.
- Remain up to date on coding changes and published fraud cases.
- Perform proactive record review by applying knowledge of coding guidelines, medical procedures, medical policies, Medicare / Medicaid policies, etc.
- Demonstrate strong communication skills to prepare superior written review summaries for submission to customers, healthcare providers, and internal staff.
- Act as a liaison for customers.
- May be required to supervise other members of the Medical Review team by providing guidance and direction to members of the team with less experience. At least 2 years of supervisory experience preferred.
- Bachelor's degree in a related discipline or equivalent experience.
- RN (Registered Nurse), LPN (Licensed Practical Nurse)preferred
- 8+ years of related experience in medical review.
- Extensive knowledge of ICD9, ICD10, CPT, HCPCS, APC, DRG, Revenue Codes, NDCs, and Medicare guidelines (including NCCI).
- Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program.
- Other certifications a plus: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Accredited Healthcare Fraud Investigator (AHFI), and Certified Fraud Examiner (CFE).
Bachelor's Degree in a related technical discipline, or the equivalent combination of education, professional training, or work experience.
- Registered Nurse (RN)
- Licensed Practical Nurse (LPN)
- Accredited Healthcare Fraud Investigator (AHFI)
- Certified Fraud Specialist (CFS)
- Certified Fraud Examiner (CFE)
- Certified in Healthcare Compliance (CHC)
- Certified Coder (CPC, CHC or other specialty coding certification)
- Computer proficiency in a Windows environment; including MS Office suite.
- Excellent verbal and written communication skills.
- Strong listening and observation skills.
- Impeccable work ethic, dependable and proactive; a problem solver.
- Ability to conduct research and locate reputable sources of information to support medical review determinations.
- Professional representative of GDIT illustrating polish, integrity, and creating trust.
- Proven ability to effectively handle cases of fraud and abuse in a discreet, confidential, and professional manner.
- Presentation skills to communicate with management and customers.
- Willingness to travel up to 10% of the time (approximately twice per year).
- Attention to detail and high level of accuracy.
- Demonstrated organizational and prioritization skills with ability to manage multiple priorities effectively.
- Able to self direct and work independently; as well as ability to collaborate effectively with peers and customers.