Fraud and Abuse Review Nurse- Remote

Gainwell Technologies LLC

7d•$64,000 - $80,000•Remote

About The Position

As a Fraud and Abuse Review Nurse- Remote at Gainwell, you can contribute your skills as we harness the power of technology to help our clients improve the health and well-being of the members they serve — a community’s most vulnerable. Connect your passion with purpose, teaming with people who thrive on finding innovative solutions to some of healthcare’s biggest challenges. Here are the details on this position.

Requirements

Graduate from an accredited School of Nursing.
Active, unrestricted RN license in good standing.
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).

Nice To Haves

Bachelor’s Degree in Nursing.

Responsibilities

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.