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

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

• Ensure compliance with established guidelines while evaluating potential overpayments, fraud, waste, and abuse.

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

• Execute desk reviews or field audits to fulfill contract obligations and uncover potential overpayments or fraudulent activities.

• Collaborate with experts in benefit integrity investigations and pharmacists.

• Prepare case summaries and deliver findings to investigators.

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

• Engage in internal and external focus groups as needed.

• Participate in onsite visits with providers and beneficiary interviews for field audits/investigations as necessary.

• Provide testimony in legal proceedings when required.

• Deliver job-specific orientation and training.

• Assist in creating training materials, resources, and programs tailored to job functions.

• Organize and schedule personal work while coordinating with the manager to prioritize projects.

• A minimum of a Bachelor's Degree is required; education may be substituted with relevant experience.

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

• Experience in Medical Review is essential.

• An active, unrestricted RN licensure is required.

• Preferred experience in Medicaid.

• Coding certification is preferred.

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

• Ability to plan and organize personal work while collaborating with the manager to prioritize projects.

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

• A drug-free workplace.

• Pre-employment background checks and drug screenings.