RN FWA Investigator & Medical Records Auditor

Neighborhood Health Plan of Rhode Island; Smithfield (RI); On-site; USD 75,000 - 110,000; Full time

Job summary

Neighborhood Health Plan of Rhode Island seeks an RN Clinical Auditor to conduct comprehensive reviews of claim data and medical records for Fraud Waste and Abuse investigations within the SIU. You will use data mining tools and payment/case systems to identify aberrant billing patterns and validate services provided according to policy and regulations.

Responsibilities include planning audits, preparing investigative summaries, notifying providers, supporting recoveries, and communicating

Qualifications

• Active RN license in RI with good standing.
• Experience with healthcare coding and clinical documentation.
• Knowledge of fraud, waste and abuse concepts and regulations.

Responsibilities

• Plan and perform audits and investigations focused on FWA.
• Utilize data mining tools to identify outliers and leads.
• Obtain and review medical records to validate services.
• Prepare investigative summaries and notify providers of findings.

Skills

Healthcare coding knowledge

Data mining tools

Regulatory compliance

Communication skills

Confidentiality

Education

Registered Nurse license (RI)

Auditing certification (CCS/CPC/CPMA/AHFI)

Tools

Microsoft Office

Job description

Neighborhood Health Plan of Rhode Island seeks an RN Clinical Auditor to conduct comprehensive reviews of claim data and medical records for Fraud Waste and Abuse investigations within the SIU. You will use data mining tools and payment/case systems to identify aberrant billing patterns and validate services provided according to policy and regulations.

Responsibilities include planning audits, preparing investigative summaries, notifying providers, supporting recoveries, and communicating