State Licensed Clinical Review Specialist

Job Summary

A company is looking for a Payment Integrity Clinical Review Specialist, Remote.

Key Responsibilities

• Collaborate with the Payment Integrity team on healthcare fraud, waste, and abuse investigations
• Conduct provider claim and clinical audits, preparing clinical review summaries with recommendations
• Review medical records and claims for PI cases involving fraud, waste, or abuse

Required Qualifications

• Active, unrestricted RN license in state of residence
• Certified Professional Coder (CPC)
• 3+ years of experience in medical claim auditing and investigating fraud, waste, and abuse
• 2+ years of experience in government, legal, law enforcement, or health insurance environments
• 2+ years of clinical medical/surgical experience