RN Clinical Auditor: Fraud & Compliance Investigator

Neighborhood Health Plan of Rhode Island; Smithfield (RI); On-site; USD 85,000 - 110,000; Full time

Job summary

Neighborhood Health Plan of Rhode Island is seeking a Registered Nurse to conduct comprehensive reviews of claim data and medical records for Fraud, Waste and Abuse investigations opened by the Special Investigations Unit. The RN will use data mining tools and billing policies to identify aberrant patterns and obtain documentation to support findings.

You will collaborate with the SIU team and interact with internal departments and external regulators to ensure proper resolution, compliance, and

Qualifications

• Registered Nurse with RI license in good standing.
• Minimum of three years in healthcare coding related to diagnosis/procedure codes.
• Knowledge of clinical medical record documentation requirements.
• High-level knowledge of medical terminology.
• Proficient with Microsoft Office.

Responsibilities

• Plan and perform audits and investigations on fraud, waste, and abuse.
• Utilize data mining tools to identify outliers and leads.
• Identify aberrant billing patterns and potential fraud.
• Review medical records to prepare investigative summaries.
• Notify providers of findings and respond to appeals and settlements.
• Prepare reporting to recoup overpayments and coordinate with Legal for recoveries.
• Manage caseloads with adherence to timelines and documentation per SIU policies.
• Collaborate with SIU and Compliance on case updates and external agencies.
• Provide testimony as required and assist with regulatory inquiries.

Skills

Registered Nurse

Healthcare coding

Communication skills

Microsoft Office

Attention to detail

Confidentiality

Education

Bachelor's Degree

Tools

Microsoft Excel

Data mining tools

Job description

Neighborhood Health Plan of Rhode Island is seeking a Registered Nurse to conduct comprehensive reviews of claim data and medical records for Fraud, Waste and Abuse investigations opened by the Special Investigations Unit. The RN will use data mining tools and billing policies to identify aberrant patterns and obtain documentation to support findings.

You will collaborate with the SIU team and interact with internal departments and external regulators to ensure proper resolution, compliance, and