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.

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, over payment 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.

• 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

• 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

• 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

• 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

• 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

• Maintain required professional certifications…