Fraud and Abuse Review Nurse- Remote

Job Duties

• Conduct objective desk and medical record audits to verify service documentation, determine appropriate administration, and validate coding/billing accuracy.
• Collaborate with internal teams (e.g., Provider Services, Contracting and Credentialing, Healthcare Services, Member Services, Claims) to collect relevant documentation for investigations.
• Identify potential healthcare fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review.
• Communicate effectively with physicians and healthcare professionals during investigations.
• Prepare accurate and timely reports detailing audit findings for internal and external stakeholders.
• Provide provider education on best practices (e.g., coding) based on national/local guidelines, contractual obligations, and regulatory requirements.
• Identify process improvement opportunities and recommend system enhancements to optimize investigative outcomes and performance.
• Data analysis of claims and utilization of benefits to identify potentially aberrant billing patterns.

Job Qualifications

• Graduate from an accredited School of Nursing.
• Active, unrestricted RN license in good standing.
• PREFERRED: Bachelor’s Degree in Nursing.
• REQUIRED EXPERIENCE: Minimum of five years of clinical nursing experience with broad clinical knowledge.
• Experience in medical review and coding/billing audits for both professional and facility-based services.
• Strong understanding of medical terminology, CPT, ICD-9/10, HCPCS, and DRG coding requirements.
• Experience with government healthcare programs (Medicare, Medicaid, SCHIP).

What You Should Expect In This Role

• Remote (work from home) environment
• Benefits on first day of employment
• 0-10% of travel

Pay and Benefits

• The pay range for this position is $64,000.00 - $80,000.00 per year, however, the base pay offered may vary depending on geographic region, internal equity, job-related knowledge, skills, and experience among other factors.