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Elite Technical
Fraud, Waste, and Abuse (FWA) Medical Record Reviewer
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Job Description
Elite Technical is seeking a Fraud, Waste, and Abuse (FWA) Medical Record Reviewer! We are seeking an experienced healthcare fraud investigator and medical record reviewer with expertise in analyzing medical documentation, claims data, provider billing patterns, and regulatory compliance requirements. Skilled in identifying potential fraud, waste, and abuse indicators through detailed record review, coding validation, and investigative research. Knowledgeable in Medicare, Medicaid, HIPAA, CPT, HCPCS, and ICD-10 guidelines, with strong analytical and case documentation abilities.
Required Skills Education:
- Associate's or Bachelor's degree in:
- Health Information Management
- Nursing
- Healthcare Administration
- Medical Coding
- Criminal Justice
- Public Health
- Related healthcare field
- Experience
- 2-5+ years reviewing medical records, claims, or healthcare documentation.
Experience in:
- Fraud, Waste, and Abuse investigations
- Medicare and Medicaid programs
- Claims auditing
- Utilization review
- Clinical documentation review
- SIU (Special Investigations Unit) operations
- Knowledge Requirements
- Medical terminology, anatomy, and physiology.
- CPT, HCPCS, and ICD-10 coding systems.
- Medicare, Medicaid, and commercial insurance regulations.
- Healthcare compliance requirements (HIPAA, OIG guidelines, CMS regulations).
- Documentation standards for healthcare providers.
- Technical Skills
- Electronic Medical Records (EMR/EHR) systems.
- Claims processing systems.
- Microsoft Office (Excel, Word, Outlook).
- Data analysis and reporting tools.
- Ability to identify documentation inconsistencies and billing irregularities.
- Certifications (Often Preferred)
- Certified Professional Coder (CPC)
- Certified Coding Specialist (CCS)
- Registered Health Information Technician (RHIT)
- Registered Health Information Administrator (RHIA)
- Certified Fraud Examiner (CFE)
- Accredited Healthcare Fraud Investigator (AHFI)
- Certified Professional Medical Auditor (CPMA)
- Key Competencies
- Strong analytical and critical-thinking skills.
- Attention to detail.
- Investigative mindset.
- Ability to interpret complex medical documentation.
- Report writing and case documentation skills.
- Knowledge of healthcare fraud schemes and abuse indicators.