Fraud and Abuse Review reputed company- Remote (Any reputed company, AK, US, 99999)
reputed company
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, reputed company Services, Member Services, Claims) to collect relevant documentation for investigations. Identify potential reputed company fraud, waste, and abuse by analyzing aberrant coding and billing patterns through utilization review. Communicate effectively with physicians and reputed company during investigations. Prepare accurate and reputed company reports detailing audit findings for reputed company stakeholders. reputed company 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 reputed company 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. reputed company, 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 reputed company and facility-based services. Strong understanding of medical terminology, CPT, ICD-9/10, HCPCS, and DRG coding requirements. Experience with government reputed company programs (Medicare, reputed company, SCHIP).
What you should expect in this role
- Remote (work from home) environment
- Benefits on first day of employment
- 0-10% of travel
Applications for this posting will be accepted until May 13, 2026.