Remote Nurse SME: Program Integrity & Audits Expert

Santa Barbara Cottage Hospital; United States; Remote; USD 100,000 - 120,000; Full time

Job summary

J29, Inc. seeks an experienced Nurse Subject Matter Expert (SME) to support potential contract work. The Nurse SME will serve as a senior clinical resource for program integrity initiatives, audits, data analysis, healthcare reviews, and FWA prevention.

Collaboration with health plans, providers, and stakeholders is essential. Responsibilities include evaluating healthcare data, reviewing medical records, identifying vulnerabilities, and developing recommendations to improve quality and

Qualifications

• Active, unrestricted RN license in at least one U.S. state or territory.
• Bachelor's degree in Nursing or related healthcare field.
• 10+ years of clinical and healthcare industry experience including medical record review, clinical auditing, risk adjustment, or healthcare program oversight.
• Strong knowledge of HCCs, risk adjustment methodologies, and coding/documentation requirements.
• Experience supporting RADV audits and reviews.
• Knowledge of HRAs and population health initiatives.
• Familiarity with CMS STAR Ratings and quality performance measures.
• Experience identifying fraud, waste, abuse, and vulnerabilities through clinical review and data analysis.

Responsibilities

• Provide clinical support to audits, data analysis, investigations, and information requests.
• Collaborate with clients, health plans, providers, and other stakeholders to support program integrity.
• Lead design and implementation of projects and assist with execution as needed.
• Develop educational materials or training to meet project goals and combat FWA.
• Review encounter data, claims, and prescription records to provide recommendations.
• Translate clinical requirements among professionals and vet technical findings for stakeholders.

Skills

Analytical skills

Communication skills

Cross-functional collaboration

Auditing knowledge

Education

Bachelor's degree in Nursing

RN license

Job description

J29, Inc. seeks an experienced Nurse Subject Matter Expert (SME) to support potential contract work. The Nurse SME will serve as a senior clinical resource for program integrity initiatives, audits, data analysis, healthcare reviews, and FWA prevention.

Collaboration with health plans, providers, and stakeholders is essential. Responsibilities include evaluating healthcare data, reviewing medical records, identifying vulnerabilities, and developing recommendations to improve quality and