Claims Fraud Clinical Analyst (RN)

FedPoint; United States; Hybrid; USD 72,000 - 97,000; Full time

Benefits offered by this job

401k plan with 100% match up to 6%

Annual bonus opportunities

Paid time off: 3 weeks vacation, 7 SIO

Health, dental, vision, disability and

Life insurance

Tuition reimbursement

Parental leave (6 weeks)

Volunteer program

Job summary

FedPoint is seeking a Claims Fraud Clinical Analyst (RN) to protect the integrity of long term care benefits. You will review medical records, evaluate claims and support investigations with clinical expertise and analytical rigor.

This role blends investigative work with healthcare compliance and risk management in a hybrid Portsmouth, NH setting. The ideal candidate holds an unrestricted RN license with at least five years of diverse nursing experience, strong communication skills, and the

Qualifications

• Must be a licensed RN with unrestricted license.
• Minimum 5 years of nursing experience in diverse healthcare settings.
• Strong ability to analyze clinical documentation and healthcare delivery practices.

Responsibilities

• Review medical records and claims documentation for eligibility and risk.
• Investigate high risk claims and referrals for potential fraud, waste or abuse.
• Conduct clinical reviews to support investigations and risk assessments.
• Evaluate eligibility, provider utilization, billing patterns and care plans.
• Collaborate with Care Coordination, Claims, Customer Service, Compliance and Risk teams.

Skills

Analytical thinking

Investigative skills

Communication

Education

Registered Nurse license

Job description

Job Overview

Claims Fraud Clinical Analyst RNProtect the Integrity of Long Term Care BenefitsAre you a Registered Nurse who enjoys investigative work critical thinking and complex case analysis Do you have experience reviewing medical records evaluating claims and identifying potential risks within healthcare programs We are seeking a Claims Fraud Clinical Analyst CFCA to join our Claims Risk Management team In this role you will leverage your clinical expertise and analytical skills to help detect prevent and minimize fraud waste and abuse within a long term care insurance program This position offers a unique opportunity for an experienced RN to move beyond direct patient care and play a key role in protecting benefit integrity while collaborating with clinical claims compliance and investigative teams

What You’ll Do

• Review and analyze medical records benefit eligibility assessments independent medical examinations and claims documentation
• Investigate high risk claims and referrals involving potential fraud waste or abuse
• Conduct clinical reviews to support active investigations and risk assessments
• Evaluate claimant eligibility provider utilization billing patterns and care plans
• Collaborate with Care Coordination Claims Customer Service Compliance and Risk Management teams
• Communicate professionally with claimants healthcare providers attorneys and internal stakeholders
• Prepare referrals for Special Investigation Units and forensic investigation teams
• Identify trends risks and opportunities to strengthen fraud prevention efforts
• Maintain professional licensure and complete required continuing education

Qualifications Required

• Current unrestricted Registered Nurse RN license
• Minimum of 5 years of nursing experience in a variety of healthcare settings
• Strong knowledge of clinical documentation and healthcare delivery practices
• Exceptional analytical investigative and critical thinking skills
• Excellent verbal and written communication abilities
• Ability to work independently while collaborating effectively across departments

Preferred

• Long term care home health or case management experience
• Experience in claims review or insurance operations
• Background investigating fraud waste or abuse within healthcare environments
• Knowledge of healthcare regulations compliance and risk management practices
• Certified Fraud Examiner CFE credential or willingness to obtain certification

What Makes You Successful

• Strong attention to detail and investigative mindset
• Ability to analyze complex medical information and identify potential concerns
• Sound clinical judgment and decision making abilities
• Confidence communicating with diverse stakeholders in challenging situations
• Ability to manage multiple priorities in a fast paced environment
• Commitment to customer service and professional excellence

Why Join Us

This position offers the opportunity to make a meaningful impact by protecting valuable long term care benefits while applying your clinical expertise in a highly specialized role If you enjoy solving complex problems reviewing medical documentation and contributing to fraud prevention and risk management efforts

Location

Location Portsmouth NH Schedule Full time 40 hours Hybrid 2 days per week in office

What to Expect on Pay

The salary range for this role is 71885 97257 per year Weve shared the full range to stay transparent but most new hires join us between the minimum 71885 and the midpoint 84571 depending on skills and experience Final compensation is based on a mix of factors including qualifications experience and education as well as internal equity and budget considerations

At FedPoint our mission is to create and deliver world class benefits experiences for our customers clients and business partners We offer a dynamic work environment where innovation and collaboration are encouraged Youll have the opportunity to make a significant impact while honing your skills and advancing your career

Benefits

• Generous 401k plan 100 match of employees contribution up to a maximum of 6 salary vests immediately
• Bonus Opportunity Qualifying employees can earn an annual bonus based on company metrics and personal performance
• Lots of paid time off 3 weeks vacation 7 sick days 3 personal days and 12 paid holidays
• Competitive benefits include health dental vision disability life legal flexible spending account FSA and Health Savings Account HSA options
• 6 weeks fully paid parental leave
• Tuition reimbursement program to support career goals
• Corporate giving and matching gifts program
• Volunteer program Paid time off to volunteer and company organized volunteering opportunities
• A wide variety of personal professional and career development programs
• Comprehensive wellness program offering a variety of resources and activities to help support your well being in the following areas career financial mental emotional physical social and community
• All offers of employment with FedPoint are conditional upon satisfactory completion of a pre employment background check
• FedPoint is an equal opportunity employer as to all protected groups under applicable federal state and local laws including protected veterans and individuals with disabilities
• If you believe you need a reasonable accommodation in order to search for a job opening or to submit an online application please call 603 433 4500
• Equal Employment Opportunity EEO Poster
• Family and Medical Leave Act FMLA Poster
• Employee Polygraph Protection Act Poster