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."

Key Duties and Responsibilities

Clinical Reviews:


* 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 ...