Healthcare Fraud, Waste and Abuse Clinical Reviewer - Remote

Integrity Advantage - Home Based

Contract

Healthcare Fraud, Waste and Abuse Clinical Reviewer – Remote

Integrity Advantage is a small woman owned business serving payers and other entities challenged with the detection, investigation and prevention of healthcare fraud, waste and abuse (FWA). We are hiring a healthcare FWA clinical reviewer to identifying aberrancies in medical records by conducting clinical reviews for healthcare fraud investigations. This is a client facing position, so excellent communication and phenomenal customer service skills are key to being selected for this position.

Essential duties and responsibilities:

  • Using knowledge of healthcare coding, conduct reviews of medical records and claims submitted to determine appropriateness and clinical necessity of codes billed against documentation provided.
  • Identify aberrancies and trends related to claim submissions by providers, facilities and pharmacies.
  • Organize and prioritize assigned reviews and make payment determinations based on coding guidelines, medical policies and other relevant regulatory requirements.
  • Perform additional research, as needed, in support of investigative reviews.
  • Compile and prepare findings identifying key areas of concern where potential overpayments have occurred.
  • Interact with clients and provide support during conversations with subject providers.
  • Perform other projects, as assigned.

Required Education / Licenses / Certifications:

  • Registered Nurse with a current, valid unrestricted license required
  • Certified Professional Coder (CPC) strongly preferred
  • Accredited Healthcare Fraud Investigator (AHFI) preferred

Experience:

  • Minimum of 3 years claims coding knowledge (billing or reviewing)
  • Minimum of 3 years clinical experience as a registered nurse
  • Minimum of 1 year experience with healthcare fraud, waste and abuse clinical reviews

Consideration will be given to candidates with a combination of experience and education that demonstrate you are able to perform the requirements of the position.

Knowledge, Skills & Abilities:

  • Above average proficiency with MS Word, Excel and PowerPoint
  • Ability to quickly adapt to different anti-fraud technology solutions
  • Knowledge of federal and state guidelines as well as ICD, CPT, HCPCS, DRG, and REV codes
  • Possess integrity, professionalism and excellent interpersonal skills; excellent communication skills, both written and oral
  • Demonstrated ability to work independently
  • Critical problem-solving skills and attention to details
  • Ability to perform within a remote team with minimal supervision

Job Type: Contract

Experience:

  • Healthcare: 3 years (Required)
  • healthcare fraud, waste and abuse: 1 year (Required)

License:

  • Registered Nurse (RN) (Required)
  • Certified Professional Coder (CPC) (Required)

Work authorization:

  • United States (Required)

Contract Length:

  • More than 1 year

Full Time Opportunity:

  • Yes