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
- 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
- Healthcare: 3 years (Required)
- healthcare fraud, waste and abuse: 1 year (Required)
- Registered Nurse (RN) (Required)
- Certified Professional Coder (CPC) (Required)
Full Time Opportunity: