Healthcare Fraud Medical Record Auditor
On-siteGladwin, Michigan, United States
Job Summary
Conduct independent, risk-based medical record reviews to assess medical necessity, coding accuracy, and adherence to Medicare, Medicaid, and commercial payer policies. Identify indicators of fraud, waste, and abuse such as upcoding, unbundling, and misrepresentation of services by applying complex regulatory requirements including CMS manuals and state Medicaid rules. Exercise professional judgment to determine audit scope, methodology, and conclusions, providing expert analyses that inform investigative referrals, overpayment determinations, and corrective action plans. Prepare defensible written audit reports detailing findings, regulatory citations, and recommended next steps while collaborating with compliance officers, investigators, and legal teams. Serve as a subject matter expert on billing, coding, and documentation standards to support policy development and continuous improvement.
Required Qualifications
- Bachelor's degree in health information management, nursing, healthcare administration, public health, or a related field
- Associate's degree in health information management, nursing, healthcare administration, public health, or a related field with a minimum of five (5) years of progressive experience in medical record auditing, healthcare compliance or program integrity forensic studies, and/or medical fraud, waste or abuse review
- High school diploma or equivalent with a minimum of eight (8) years of progressive professional experience in medical record auditing, healthcare compliance or program integrity forensic studies, and/or medical fraud, waste or abuse review
- Minimum of three (3) years of progressive experience in medical record auditing, healthcare compliance or program integrity forensic studies, and/or medical fraud, waste or abuse review
- Minimum of three (3) years of professional level investigative experience involving healthcare fraud, complex compliance investigations, regulatory enforcement, or government program integrity
- Demonstrated experience applying federal and state healthcare regulations in complex audit environments
- Professional experience in performing high-level analytical research and evaluative skills
- Experience with and proficiency in FWA data analysis tools and software
- Advanced knowledge of CPT, HCPCS, ICD-10-CM/PCS Coding Systems, Medicare/Medicaid reimbursement methodologies and federal/state fraud and abuse laws/regulations
- Proficiency in the use of Microsoft Office Suite applications
- Ability to maintain a high level of productivity with strong attention to detail and organizational skills
- Strong oral and written interpersonal communication skills
- Strong analytical, critical-thinking, and technical written communication skills
- Ability to exercise discretion and independent judgment in matters of significance
- Some travel may be required for professional investigative activities, interviews, or continuing education
Desired Qualifications
- Demonstrated working knowledge of Managed Care and the Medicaid and Medicare programs
- Professional certifications demonstrating specialized expertise, such as Certified Fraud Examiner (CFE), Certified in Healthcare Compliance (CHC), Certified Internal Auditor (CIA), Accredited Healthcare Fraud Investigator (AHFI) or healthcare coding certifications (CPC, CPMA, etc.)
- Prior service with healthcare regulatory or enforcement agencies or in senior-level compliance investigation roles (retired or former OIG or MFCU experience)
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