FWA Nurse Reviewer

Position Summary

The Nurse Reviewer for FWA Clinical Reviews is essential in identifying and preventing healthcare fraud, waste, and abuse (FWA). The Nurse Reviewer analyzes medical claims, conducts clinical reviews, and collaborates with teams to ensure healthcare services are appropriate and necessary. Additionally, the position involves preparing reports and contributing to FWA prevention strategies while maintaining confidentiality.

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

Clinical Reviews

Key Duties and Responsibilities

• Assess medical records, claims data, and supporting documentation to determine the appropriateness and necessity of healthcare services.
• Analyze clinical information using evidence-based guidelines, payer policies, and industry standards.
• Evaluate medical necessity, appropriateness, and the quality of healthcare services rendered.
  
  

Fraud, Waste, And Abuse Investigations

• Identify patterns indicative of potential fraud, waste, or abuse in claims and provider behavior.
• Collaborate with FWA investigators, legal counsel, and other teams to pursue cases.
• Prepare cases for referral to the client, the networks, the medical necessity review agency, the FWA reviewer and regulatory agencies as needed.
  
  

Documentation And Reporting

• Document findings clearly, providing evidence to support conclusions.
• Prepare comprehensive reports and summaries of clinical reviews and investigations.
• Maintain meticulous records of all review activities.
  
  

Collaboration And Communication

• Work closely with multidisciplinary teams, including the client, the networks, the medical necessity review agency, the FWA reviewer, med investigators, data analysts, and legal professionals, to develop comprehensive strategies.
• Provide expert clinical insights and guidance for FWA prevention efforts.
• Present findings to the client and stakeholders in a clear, professional manner.
  
  

Compliance And Continuous Improvement

• Stay informed about federal and state regulations, payer policies, and industry best practices related to FWA.
• Participate in training and professional development opportunities.
• Contribute to the enhancement of FWA review protocols and processes.
• Keep required certifications current.
• Performs other duties as assigned.
  
  

Minimum Qualifications

• A strong clinical background and expertise in healthcare compliance and medical auditing.
• Bachelor's degree in nursing (BSN) or equivalent education and experience.
• Active and unrestricted Registered Nurse (RN) license in the state of employment.
• 3-5 years of clinical experience in healthcare settings such as hospitals, outpatient care, or managed care organizations.
• 3-5 years' Experience in utilization review, case management, or quality assurance.
• 3 -5 years' Experience in fraud, waste, and abuse investigations or medical auditing.
• 3-5 years' Experience with medical coding systems (e.g., ICD-10, CPT) and healthcare regulations.
• Strong analytical and critical thinking skills.
• Excellent written and verbal communication abilities.
• Proficient in Outlook, Excel and Microsoft Word.
• Attention to detail and ability to handle sensitive information with discretion.
• Strong Organizational Skills
  
  

Preferred Qualifications

• Certified Fraud Examiner (CFE) or the equivalent.
• Accredited Health Care Fraud Investigator (AHFI) or the equivalent.
• Certified Professional Coder (CPC) or Certified Coding Specialist (CCS) or the equivalent.
• Certified in Healthcare Compliance (CHC) or the equivalent.
• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee of this job. Duties, responsibilities and activities may change at any time with or without notice.
  
  

Working Conditions/Physical Effort

• Prolonged periods of sitting at a desk and working on a computer.
• Occasional travel for meetings, training, or on-site investigations.
• Typically performed in an office environment with remote work opportunities.
• Must be able to lift up to 15 pounds.
  
  

Disability Accommodation

Consistent with the Americans with Disabilities Act (ADA) and other applicable federal and state law, it is the policy of Zenith American Solutions to provide reasonable accommodation when requested by a qualified applicant or employee with a disability, unless such accommodation would cause an undue hardship. The policy regarding requests for reasonable accommodation applies to all aspects of employment, including the application process. If reasonable accommodation is needed, please contact the Recruiting Department at recruiting@zenith-american.com , and we would be happy to assist you.

Zenith American Solutions

Real People. Real Solutions. National Reach. Local Expertise.

We are currently looking for a dedicated, energetic employee with the necessary skills, initiative, and personality, along with the desire to get the most out of their working life, to help us be our best every day.

Zenith American Solutions is the largest independent Third Party Administrator in the United States and currently operates over 44 offices nationwide. The original entity of Zenith American has been in business since 1944. Our company was formed as the result of a merger between Zenith Administrators and American Benefit Plan Administrators in 2011. By combining resources, best practices and scale, the new organization is even stronger and better than before.

We believe the best way to realize our better systems for better service philosophy is to hire the best employees. We're always looking for talented individuals who share our dedication to high-quality work, exceptional service and mutual respect. If you're interested in working in an environment where people - employees and clients - really matter, consider bringing your talents to Zenith American!

We realize the importance a comprehensive benefits program to our employees and their families. As part of our total compensation package, we offer an array of benefits including health, vision, and dental coverage, a retirement savings 401(k) plan with company match, paid time off (PTO), great opportunities for growth, and much, much more!