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).