Remote Compliance Auditor
Remote Compliance Auditor
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2years
Not Disclosed
Salary Not Disclosed
1 Vacancy
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 noncompliance.
- Conduct retrospective case reviews onsite provider audits and recipient interviews.
- Review billing practices for upcoding duplicate billing and unbundling of services using ICD10 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 onsite 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.
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!
Employment Type
Full Time
