Nurse Reviewer - Fraud, Waste, and Abuse Clinical Reviews

Title: Nurse Reviewer - Fraud, Waste, and Abuse Clinical Reviews Department: Claims

Bargaining Unit: NBU Grade: N/A

Position Type: Exempt Hours per Week: 40

Position Summary

The Nurse Reviewer - FWA Clinical Reviews is responsible for conducting clinical reviews to identify, investigate, and prevent healthcare fraud, waste, and abuse. This role requires a strong clinical background combined with an understanding of regulatory and compliance issues within healthcare. The Nurse Reviewer will collaborate with multidisciplinary teams to ensure that claims are appropriate, necessary, and align with established guidelines and standards of care.

"Has minimum necessary access to Protected Health Information (PHI) and Personally Identifiable Information (PII) by Job Description/Role."

Key Duties and Responsibilities

Conduct Clinical Reviews:

• Review medical records, claims data, and other relevant documentation to assess the appropriateness of healthcare services and identify potential fraud, waste, and abuse.
• Analyze clinical information against evidence-based guidelines, standards of care, and payer policies.
• Determine the medical necessity, appropriateness, and quality of healthcare services rendered.

Fraud, Waste, and Abuse Investigations:

• Identify patterns of potentially fraudulent, wasteful, or abusive practices in claims and provider behavior.
• Collaborate with FWA investigators, legal counsel, and other relevant departments to develop and pursue FWA cases.
• Assist in preparing cases for referral to law enforcement or regulatory agencies when necessary.

Documentation and Reporting:

• Document clinical findings clearly and concisely, supporting decisions with appropriate clinical evidence.
• Prepare detailed reports and summaries of clinical reviews and investigations.
• Maintain accurate and up-to-date records of all review activities.

Collaboration and Communication:

• Work closely with other members of the FWA team, including investigators, data analysts, and legal professionals, to develop comprehensive FWA strategies.
• Provide expert clinical insight and guidance to support FWA investigations.
• Communicate findings to internal and external stakeholders as required.

Compliance and Continuous Improvement:

• Stay current with federal and state regulations, payer policies, and industry best practices related to FWA.
• Participate in ongoing training and professional development opportunities.
• Contribute to the development and improvement of FWA processes and protocols.
• Performs other duties as assigned.

Minimum Qualifications

• Bachelor's degree in nursing (BSN) or an equivalent combination of education and experience.
• Active and unrestricted Registered Nurse (RN) license in the state of employment.
• Minimum of 3-5 years of clinical experience in healthcare settings such as hospitals, outpatient care, or managed care organizations.
• Prior experience in utilization review, case management, or quality assurance.
• Experience in FWA investigations or medical auditing is highly desirable.
• Strong analytical and critical thinking skills with the ability to evaluate complex clinical information.
• Excellent written and verbal communication skills.
• Proficiency in medical terminology, coding systems (e.g., ICD-10, CPT), and healthcare regulations.
• Ability to work independently and as part of a multidisciplinary team
• High level of integrity and ethical standards.
• Attention to detail and accuracy.
• Ability to handle sensitive and confidential information with discretion.

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