Senior Payment Integrity Specialist

Job Summary

A company is looking for a Senior Payment Integrity Clinical Review Specialist (Remote).

Key Responsibilities

• Collaborate with a team to investigate and review instances of health care fraud and abusive conduct
• Conduct provider claim and clinical audits, preparing case summaries with recommendations
• Perform clinical reviews of medical records and claims data to detect fraud, waste, and abuse

Required Qualifications

• Active, unrestricted RN license in state of residence
• 5+ years of experience in medical claim processing, auditing, or fraud investigations
• 3+ years of experience in a government, legal, or health insurance environment
• 3+ years of clinical medical/surgical experience
• 2+ years of experience identifying billing abnormalities and fraudulent activity