Offer summary

Qualifications:

Registered Nurse (RN) license is required., Experience in claims analysis, medical records review, and compliance investigations., Knowledge of medical billing, fraud detection, and relevant regulations., Proficiency in Microsoft Office and strong communication skills..

Key responsibilities:

Analyze claims data, medical records, and provider documentation for discrepancies and fraud.

Conduct provider audits, case reviews, and interviews with recipients.

Prepare reports and recommend sanctions for violations.

Participate in legal proceedings, respond to inquiries, and maintain case records.

Job description

Position Overview:

We are seeking a Registered Nurse (RN) to review and evaluate medical necessity, appropriateness, quality, and compliance of services rendered by providers. This role involves claims analysis, provider audits, fraud detection, and regulatory enforcement to ensure compliance with state and federal regulations.

Key Responsibilities:

Analyze claims data, medical records, and provider documentation to identify discrepancies, fraud, or non-compliance.
Conduct retrospective case reviews, on-site provider audits, and recipient interviews.
Review billing practices for upcoding, duplicate billing, and unbundling of services using ICD-10, CPT, and HCPCS manuals.
Prepare reports, case findings, and recommend sanctions when violations are identified.
Coordinate and participate in teleconferences, hearings, and legal proceedings with the Office of General Counsel and other agencies.
Respond to provider complaints and compliance inquiries via hotline, email, and official reports.
Maintain case tracking systems and contribute to policy recommendations and process improvements.
Travel as needed for on-site reviews, meetings, and training.

Requirements:

Registered Nurse (RN) license (required).
Experience with claims analysis, medical records review, and compliance investigations.
Knowledge of MA regulations, medical billing, and fraud detection.
Proficiency in Microsoft Office
Strong written and verbal communication skills for reporting and testimony.
Ability to work independently, maintain confidentiality, and manage case files efficiently.
Must be able to travel to Harrisburg, PA for training

Preferred Qualifications:

Experience with Managed Care Organizations (MCOs) and HCBS providers.
Familiarity with PROMISe claims systems and Fraud Abuse Detection Systems (FADS).
Prior experience in legal proceedings, hearings, or administrative compliance

This is an opportunity to play a critical role in ensuring healthcare integrity and protecting public funds. Apply today to join our team!

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