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:
Fraud, Waste, and Abuse Investigations:
Documentation and Reporting:
Collaboration and Communication :
Compliance and Continuous Improvement:
Minimum Qualifications
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
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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