Job Description

Job Description

Job Description

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.

Preferred Qualifications

• Advanced degrees or certifications in healthcare fraud examination, compliance, or related fields are a plus.

*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.
• This position may require occasional travel to attend meetings, training, or conduct on-site investigations.
• The work is typically performed in an office environment with a combination of remote work opportunities.
• Must be able to lift 15 pounds at times.

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 seeking an experienced Nurse Reviewer - Fraud, Waste, and Abuse Clinical Reviews 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 40 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 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!

Internals to Apply:

If you meet the minimum qualifications and are interested in applying for the above position, please submit an application.

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