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Medical Review Auditor (Fraud Waste and Abuse)

Cotiviti -
Remote

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Job Details

Full-time
$70,000 - $91,000 a year
12 days ago

Benefits

Paid holidays
Disability insurance
Health insurance
Dental insurance
Paid time off
Family leave
Vision insurance
Life insurance

Qualifications

Healthcare financial misconduct investigations
Nursing
National Correct Coding Initiative (NCCI) guidelines
RN License
Audit report preparation
Computer literacy
CMS
Process improvement
Healthcare documentation compliance audits
Mid-level
Inspection reporting and documentation
State healthcare regulations
Audit Reporting
Certified Professional Coder
CMS regulatory compliance
Retrospective medical coding audits
Bachelor's degree
Health insurance knowledge
Task prioritization
Health policy
Certified Coding Specialist
Centers for Medicare & Medicaid Services (CMS) billing regulations
LPN
Productivity software
Data accuracy checks
Insurance claims auditing
Clinical documentation standards
Healthcare claims compliance audits
2 years
Documentation review

Full Job Description

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.

This job description is intended to describe the general nature and level of work being performed and is not to be construed as an exhaustive list of responsibilities, duties, and skills required. This job description does not constitute an employment agreement and is subject to change as the needs of Cotiviti and the requirements of the job change.

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 $70,000 to $91,000 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: 8/21/2026

Applications are assessed on a rolling basis. We anticipate that the application window will close on 10/21/2026, but the application window may change depending on the volume of applications received or close immediately if a qualified candidate is selected.

#senior

#LI-SL1

#LI-Remote

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