Healthcare Fraud Medical Record Auditor

Overview

Company Overview

Advance Your Career in Insurance Claims with Allied Universal® Compliance and Investigation Services. Allied Universal® Compliance and Investigation Services is the premier destination for a career in insurance claim investigation. As a global leader, we provide dynamic opportunities for claim investigators, SIU investigators, and surveillance investigators. Our team is committed to innovation and excellence, making a significant impact in the insurance industry. If you’re ready to grow with the best, explore a career with us and make a difference.

Job Description

Allied Universal® is hiring a Healthcare Fraud Medical Record Auditor. The Healthcare Fraud Medical Record Auditor is responsible for conducting complex, independent medical record reviews to identify, evaluate, and document potential fraud, waste, abuse, and non-compliance with federal and state healthcare program requirements. The role requires advanced clinical coding and regulatory expertise, the exercise of professional judgment, and the ability to interpret medical necessity, coverage, and documentation standards across multiple provider types and payment models. The Healthcare Fraud Medical Record Auditor operates with significant autonomy, applies specialized knowledge acquired through formal education and/or professional certification, and provides expert analyses that support investigations, referrals, overpayment determinations, corrective actions, and potential enforcement proceedings. The Auditor serves as a Subject Matter Expert (SME) in billing, coding, documentation and suggests investigative areas potentially unknown by an investigator. Some travel may be required for professional investigative activities, interviews, or continuing education.

RESPONSIBILITIES

Advanced Medical Record Review and Analysis

• Independently conduct comprehensive, risk-based reviews of medical records to assess:
• Medical necessity
• Coding accuracy and compliance
• Documentation sufficiency
• Adherence to Medicare, Medicaid, and commercial payer coverage policies
• Interpret and apply complex regulatory requirements, including CMS manuals, NCDs, LCDs, state Medicaid rules, and payer policies

Fraud and Abuse Identification

• Identify clinical and coding indicators of potential fraud, waste, and abuse, including:
• Upcoding, unbundling, and billing for medically unnecessary services
• Misrepresentation of services rendered
• Patterns indicative of systemic non-compliance or abusive billing practices
• Evaluate aberrant billing patterns in coordination with data analytics, investigative, and legal teams

Professional Judgment and Advisory Role

• Exercise independent professional judgment in determining audit scope, methodology, findings, and conclusions
• Provide expert clinical and coding opinions that inform:
• Investigative referrals
• Overpayment calculations
• Corrective action plans
• Administrative or legal proceedings
• Serve as a subject matter expert for internal stakeholders regarding documentation, coding, and medical necessity standards

Reporting and Documentation

• Prepare clear, defensible written audit reports summarizing:
• Findings and methodologies
• Regulatory citations
• Clinical rationale
• Recommended actions or next steps
• Ensure reports meet evidentiary and regulatory standards suitable for audits, appeals, referrals, or enforcement actions

Collaboration and Leadership Support

• Collaborate with compliance officers, investigators, attorneys, clinicians, and executive leadership
• Provide professional guidance and education to internal teams on evolving coding, documentation, and fraud risk trends
• Support policy development and continuous improvement of audit and compliance programs

Continuous Professional Development

• Maintain required professional certifications and stay current on regulatory changes, coding updates, and enforcement trends
• Participate in advanced training related to healthcare fraud, audit methodologies, and regulatory compliance

QUALIFICATIONS (MUST HAVE)

• Must possess one or more of the following:
• 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

PREFERRED QUALIFICATIONS (NICE TO HAVE)

• 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)

BENEFITS

• Medical, dental, vision, basic life, AD&D, retirement plan and disability insurance
• Seven paid holidays annually, sick days available where required by law
• Vacation time offered at an initial accrual rate of 3.08 hours biweekly; unused vacation is only paid out where required by law

Closing

Allied Universal® is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race/ethnicity, age, color, religion, sex, sexual orientation, gender identity, national origin, genetic information, disability, protected veteran status or relationship/association with a protected veteran, or any other basis or characteristic protected by law. For more information: www.aus.com

If you have difficulty using the online system and require an alternate method to apply or require an accommodation, please contact our local Human Resources department. To find an office near you, please visit: www.aus.com/offices.

Requisition ID

2026-1622046