RN Claims Fraud & Risk Analyst

FedPoint; Newington (NH); Hybrid; USD 72,000 - 97,000; Full time

Benefits offered by this job

401k with match

Bonus opportunity

Paid time off

Health, dental, vision benefits

Parental leave

Tuition reimbursement

Volunteer program

Job summary

FedPoint seeks an experienced RN to join the Claims Risk Management team as a Fraud Clinical Analyst (CFCA). You will review medical records, evaluate claims, and support investigations to prevent fraud, waste, and abuse within long-term care programs.

This role offers collaboration with clinical, claims, compliance, and investigative teams, with a focus on protecting benefit integrity while advancing your clinical expertise. Location: Portsmouth, NH; Schedule: Full-time, Hybrid 2 days in office.

Qualifications

• 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.

Responsibilities

• 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.

Skills

Analytical skills

Communication skills

Independent work

Cross-functional collaboration

Education

RN license (unrestricted)

Job description

FedPoint seeks an experienced RN to join the Claims Risk Management team as a Fraud Clinical Analyst (CFCA). You will review medical records, evaluate claims, and support investigations to prevent fraud, waste, and abuse within long-term care programs.

This role offers collaboration with clinical, claims, compliance, and investigative teams, with a focus on protecting benefit integrity while advancing your clinical expertise. Location: Portsmouth, NH; Schedule: Full-time, Hybrid 2 days in office.