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

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

• Ensure adherence to established guidelines while evaluating potential overpayments, fraud, waste, and abuse.

• Examine cases involving beneficiaries, providers, and/or pharmacies.

• Carry out desk reviews or field audits to fulfill contract obligations and detect signs of potential overpayment or fraud.

• Collaborate with benefit integrity investigation specialists and pharmacists.

• Prepare case summaries and relay findings to investigators.

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

• Engage in internal and external focus groups as needed.

• Participate in provider onsite visits and beneficiary interviews during field audits/investigations.

• Provide testimony at legal proceedings when required.

• Deliver job-specific orientation and training.

• Assist in the development of training content, resources, and programs.

• Organize and manage own workload while collaborating with the manager to prioritize tasks.

• A minimum of a Bachelor's Degree is required.

• 2 - 4 years of experience is necessary; 5 - 7 years is preferred.

• Experience in Medical Review is mandatory.

• Current, active, and unrestricted RN licensure is essential.

• Familiarity with Medicare claims and regulations is preferred.

• Coding certification is a plus.

• Successful completion of pre-employment background checks and drug screenings is required.

• Capacity to conduct provider onsite visits and beneficiary interviews as needed for field audits/investigations.

• Ability to provide testimony at various legal proceedings when necessary.

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

• A drug-free workplace.

• Employment is contingent upon successful completion of pre-employment background checks and drug screenings.