This is a fully remote position, open to applicants in United States.

• Conduct reviews of medical records and claims for Medicare, Medicaid, and other claims data.

• Assess beneficiary, provider, and pharmacy cases for possible overpayment, fraud, waste, and abuse.

• Execute desk reviews or field audits to fulfill contract obligations and identify signs of potential overpayment or fraud.

• Collaborate with benefit integrity investigation specialists and pharmacists.

• Prepare case summaries and present findings to investigators.

• Carry out case-specific or plan-specific data entry and reporting tasks.

• Engage in both internal and external focus groups as needed.

• Participate in provider onsite visits and beneficiary interviews for field audits/investigations when required.

• Provide testimony in legal proceedings as necessary.

• Deliver job-specific orientation and training sessions.

• Assist in the creation of training materials, resources, and programs.

• Organize and manage personal workload with guidance from management.

• A minimum of a Bachelor's Degree is required (experience may be substituted).

• 2 to 4 years of relevant experience is required; 5 to 7 years is preferred.

• Experience in Medical Review is required.

• A current, active, and unrestricted RN license is mandatory.

• Experience with Medicare is preferred.

• Coding certification is preferred.

• Completion of pre-employment background checks and drug screenings is required for job offers.

• Equal Opportunity Employer for Minorities, Females, Protected Veterans, and Individuals with Disabilities.

• A drug-free workplace environment.

• Job offers are contingent upon successful completion of pre-employment background checks and drug screenings.