RN Clinical Auditor (43914)

Job description

Job DetailsJob Location: Smithfield, RI - Smithfield, RI 02917Position Type: Full TimeEducation Level: Bachelors DegreeTravel Percentage: NoneJob Shift: DaytimeJob Category: Professional / ExperiencedResponsible for conducting comprehensive review of claim data and /or medical record documentation related to Fraud Waste and Abuse (FWA) investigations opened by the Special Investigations Unit (SIU) from various internal and/or external sources. Position requires use of computer-based data mining tools, claim payment and case management systems to identify aberrant or potentially fraudulent billing patterns. The RN Clinical Auditor will obtain and review medical record documentation to validate authorized, billed and paid services were provided according to State and Federal regulations/guidelines, Neighborhood benefit coverage and payment policies, medical necessity and standards of care. This role works collaboratively with the entire SIU team and communicates with internal business areas as applicable related to the case as well as external State and Federal regulatory and law enforcement agencies as necessary. Duties and Responsibilities: Responsibilities include, but are not lim...