Remote Compliance Auditor
Description du poste:
• Analyze claims data, medical records, and provider documentation to identify discrepancies, fraud, or non-compliance.
• Conduct retrospective case reviews, on-site provider audits, and recipient interviews.
• Review billing practices for upcoding, duplicate billing, and unbundling of services using ICD-10, CPT, and HCPCS manuals.
• Prepare reports, case findings, and recommend sanctions when violations are identified.
• Coordinate and participate in teleconferences, hearings, and legal proceedings with the Office of General Counsel and other agencies.
• Respond to provider complaints and compliance inquiries via hotline, email, and official reports.
• Maintain case tracking systems and contribute to policy recommendations and process improvements.
• Travel as needed for on-site reviews, meetings, and training.
Exigences:
• Registered Nurse (RN) license (required)
• Experience with claims analysis, medical records review, and compliance investigations.
• Knowledge of MA regulations, medical billing, and fraud detection.
• Proficiency in Microsoft Office
• Strong written and verbal communication skills for reporting and testimony.
• Ability to work independently, maintain confidentiality, and manage case files efficiently.
• Must be able to travel to Harrisburg, PA for training
Avantages:
Apply Now
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• Analyze claims data, medical records, and provider documentation to identify discrepancies, fraud, or non-compliance.
• Conduct retrospective case reviews, on-site provider audits, and recipient interviews.
• Review billing practices for upcoding, duplicate billing, and unbundling of services using ICD-10, CPT, and HCPCS manuals.
• Prepare reports, case findings, and recommend sanctions when violations are identified.
• Coordinate and participate in teleconferences, hearings, and legal proceedings with the Office of General Counsel and other agencies.
• Respond to provider complaints and compliance inquiries via hotline, email, and official reports.
• Maintain case tracking systems and contribute to policy recommendations and process improvements.
• Travel as needed for on-site reviews, meetings, and training.
Exigences:
• Registered Nurse (RN) license (required)
• Experience with claims analysis, medical records review, and compliance investigations.
• Knowledge of MA regulations, medical billing, and fraud detection.
• Proficiency in Microsoft Office
• Strong written and verbal communication skills for reporting and testimony.
• Ability to work independently, maintain confidentiality, and manage case files efficiently.
• Must be able to travel to Harrisburg, PA for training
Avantages:
Apply Now
Apply Now