RN Fraud Investigator

A-Line Staffing Solutions; Harrisburg (Dauphin County); Remote; USD 60,000 - 80,000; Full time

Job summary

A-Line Staffing Solutions is hiring a full-time RN Fraud Investigator in Harrisburg, PA. The role involves detailed analysis of claims, compliance monitoring, and participating in legal processes. Candidates must hold a valid RN License in Pennsylvania and possess strong analytical skills. Enjoy a remote work setup after training with competitive pay and benefits.

Benefits

401(k) with company match after 1 year

Benefits available after 90 days

Qualifications

• RN License in Pennsylvania is required.
• Entry-level position with responsibilities involving healthcare compliance and fraud investigation.
• Strong analytical and communication skills are essential.

Responsibilities

• Analyze paid claims and itemized bills to identify discrepancies.
• Prepare summaries and coordinate cases for potential legal actions.
• Participate in training and managed care projects.

Skills

Critical Thinking

Attention to Detail

Analytical Skills

Education

RN License in PA

Job description

4 days ago Be among the first 25 applicants

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A-Line Staffing is now hiring a RN Fraud Investigator. This will be full time / 40+ hours per week.

If you are interested in this RN Fraud Investigator Opportunity, please contact Michelle at 586-422-1171 or [e-mail]

RN Fraud Investigator Hours

• 8am – 4pm (30 min lunch)
• 8 weeks of training in Harrisburg, PA office
• Fully Remote after training, but one day in Harrisburg, PA office PER WEEK required
  
  

RN Fraud Investigator Compensation

• The pay for this position is $31.00 an hour paid bi-weekly
• Benefits are available to full-time employees after 90 days of employment
• A 401(k) with a company match is available for full-time employees with 1 year of service on our eligibility dates
  
  

RN Fraud Investigator Responsibilities

• Identify discrepancies through the analysis of paid claims, itemized bills, and computer reports through the Fraud Abuse Detection System(FADS). This includes but is not limited to analysis of paid claims for patterns identified with high-cost, high-volume providers, and potential cases for review.
• Select, review, analyze and evaluate cases retrospectively to monitor compliance with State and Federal Regulations. Services are monitored for medical necessity and quality of care. Verifying that services ordered were rendered, and all rendered services were ordered and are appropriate. Analyze for up coding, duplicated billing and unbundling of services billed. Use the ICD-9CM diagnosis and procedure manuals, coding clinics, CPT and HCPCS manuals, and other related manuals to determine that the paid claim was billed appropriately.
• Prepare case findings, prepare preliminary and final letters to providers, research and utilize appropriate MA regulations, MA bulletins and federal regulations. Keep the section supervisor informed of case development and progress as well as keep the Bureau’s Case Tracking system and the Sections tracking system updated for each active case.
• Coordinate and participate in teleconferences, when requested by the provider, scheduling times/dates with supervisor, Division Director, physician consultants and/or other parties involved with the case.
• Prepare claims to recover money for violations identified during the review process.
• Coordinate cases with the Office of General Counsel (Legal Office) in preparation for testifying at provider hearings, potential face-to-face hearings and other court proceedings. As well as discussing recommended sanctions for MA violations in accordance with Department guidelines.
• Respond to complaints from multiple sources including, but not limited to MCO, MA Provider Compliance Hotline, OMAPTips web site, letters, e-mail and phone.
• Prepare potential cases of fraud according to established procedures for referral to the Office of Attorney General’s Medicaid Fraud Control Section.
• Prepare summaries of findings, reports, charts, forms and other related materials using Word and Excel computer programs to ensure efficient operations.
• Participate in managed care monitoring in conjunction with the Bureau’s Managed Care Section’s ongoing managed care projects.
• Participate in research and special study projects that identify and impact health care services delivered to MA recipients and paid for by the MA Program.
• Attend in-service training to ensure proficiency and effectiveness of program operations.
• Participate in conferences, meetings, seminars and work groups related to sections duties and responsibilities.
• Perform other related duties and special projects as assigned by the Supervisor in order to meet the goals and objectives of BPI.
  
  

RN Fraud Investigator Requirements

• RN License in PA
  
  

If you think this RN Fraud Investigator Position is a good fit for you, please reach out to me - feel free to call, e-mail, or apply to this posting!

Seniority level

• Seniority level

  Entry level

Employment type

• Employment type

  Full-time

Job function

• Job function

  Health Care Provider

• Industries

  Staffing and Recruiting

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