Clinical Fraud Audit Specialist

Spectraforce Technologies
United States, North Carolina, Raleigh
500 West Peace Street (Show on map)
Aug 10, 2026
Position Title: Clinical Fraud Audit Specialist Work Location: Remote role (Only in AZ) Assignment Duration: 12 Months Job Responsibilities Demonstrates ability to complete reviews utilizing, but not limited to, appropriate benefit plans, policies, guidelines, claims processing system, member enrollment, provider contracts, communication records, and precertification systems. Assumes responsibility for in-depth analysis and final resolution of claims requiring clinical review according to department policy, State, Federal requirements, as applicable. This may involve coordinating with other departments, plans, providers, business, and government agencies. Maintains effective communication (verbal and written), both formal and informal, with internal and external customers. Maintains knowledge of activities in assigned area and possesses the ability to provide assistance as necessary to the SIU staff and with other departments. Maintains current knowledge of department policies, medical policy guidelines, benefits plans, and utilization criteria for all lines of business as it relates to the processing of Medical Review claims. Analyzes and monitors claims for trends. These trends may illustrate an educational need; need for a referral to a different department; need for updating a policy/guideline. Makes specific written recommendations to SIU manager with demonstrated ability to follow through on ideas. Collaborates review findings and actions with appropriate SIU staff (e.g., provider education, peer meetings with providers, financial recoveries, referrals to State and/or Federal agencies). Accumulates and reports statistics relative to inventory and timeliness. Submits ad hoc reports as necessary. Identifies needs regarding enhancements to systems and/or processes. Meets quality, quantity, and timeliness standards to achieve department performance goals as defined within the department guidelines. Actively participates on task force(s) as assigned and undertakes and completes special projects. Coordinates processing claims resolution with other departments. Attend seminars/webinars annually to stay current on fraud, waste, and abuse trends and issues. Testify and give depositions as an expert witness in legal proceedings. Maintain chain of custody on all documents, documenting all stages of each review. Create, update, and follow standard departmental operating procedures, policies, confidentiality, and security guidelines. Perform all other duties as assigned. Participates in continuing education and current developments in fields of managed care; attends courses offered by Corporate Training and Development Department and the Medical Services division; participates in appropriate computer-related educational offerings as relates to position function. Skills 1. Required Job Skills Intermediate PC proficiency. Intermediate skill in use of office equipment, including copiers, fax machines, scanner, and telephones. Intermediate skill in Word and Excel. Knowledge of healthcare coding, medical terminology, billing processes, and health insurance reimbursement. 2. Required Professional Competencies Maintain confidentiality and privacy. Strong current clinical knowledge. Interpret and translate policies, procedures, programs, contracts, benefits, and guidelines. Capable of investigative and analytical research. Navigate, gather, input, and maintain data records in multiple system applications. Follow and accept instructions and direction. Establish and maintain working relationships in a collaborative team environment. Understand, evaluate, interpret, and explain complex information clearly and concisely (verbally and in writing). Strong organizational and planning skills; critical thinking skills; ability to work with multiple priorities under limited time constraints. Establish and maintain working relationships in a collaborative team environment. Independent and sound judgment with good problem-solving skills (Applies to All Levels). Working knowledge of medical terminology and coding. Ability to assist in training of new and existing staff (Applies to Levels 2-3). 3. Required Leadership Experience and Competencies Proven leadership and assistance through positive reinforcement of processes and company policies (Level 3). Perform special projects and analyze inventory at a high functioning level. Preferred Competencies 1. Preferred Job Skills Advanced PC proficiency. Basic knowledge of regulations and laws pertaining to insurance fraud and judicial processes relating to fraud prosecutions. 2. Preferred Professional Competencies Working knowledge of McKesson InterQual criteria (Applies to All Levels). Education 1. Required Work Experience Level 1 - 1-2 years related medical coding/auditing experience and/or clinical field of practice. No prior fraud, waste, and abuse experience necessary. 2. Required Education Level 1 - Associate's Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program or equivalent combination of education and experience (CPC, CCS, CPMA) within 6 months of starting and have knowledge of ICD-10 and CPT/HCPC coding guidelines and terminology. 3. Required Licenses Active, current, and unrestricted State of Arizona license to practice as a health professional, including RN and LPN for Level 2 and 3. 4. Required Certifications Level 1 - CPC, CCS, CPMA within 6 months of starting. Preferred Qualifications 1. Preferred Work Experience 2 years of experience in related medical coding/auditing. 2 years of experience in utilization review, quality assurance, or health insurance industry field. 2. Preferred Education Bachelor's Degree in nursing or related field of study. 3. Preferred Certifications CPC - Certified Professional Coder. CCS - Certified Coding Specialist.