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Health Care Fraud Review Nurse

This job is available in 2 locations

Health Care Fraud Review Nurse

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You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility.

Position Purpose: The Health Care Fraud Review Nurse-CA Only is responsible for performing and identifying health care fraud investigations by reviewing and researching potential fraudulent/abusive activities through claims interpretation, medical record review, and medical policy interpretation. This position is also responsible for educating and advising staff on medical policies, procedures, ensuring the accuracy of all Program Integrity case audits, and assisting in determining correct plan of action for Program Integrity case activity.
This position reviews entire patient records against codes utilized by providers on all types of claim forms. (i.e. CPT, ICD-9, HCPC, revenue, discharge coding, DRG, etc) to determine if the claim was billed appropriately, if the claim was medically necessary, and services were provided as billed.
This position must have a high level of expertise of all codes used in billing claims, all types of claim forms, be able to identify aberrant medical procedures, be able to interpret medical policies, and be prepared to justify decisions made in civil/criminal proceedings (i.e. testify in court proceedings as an expert witness).
This position is a resource to all levels of medical review nurses in identifying aberrant billing practices, determining medical necessity and appropriateness for all potential fraudulent cases.
  • Demonstrates regular, reliable and predictable attendance.

  • Performs audits to identify inappropriate billing practices and determines medical necessity through extensive review of claims data, medical records, policies, and interpretation of standards of practice.

  • Justifies decisions and prepares case audit, with supporting documentation, for possible review by US Attorney for civil/criminal prosecution.

  • Advises associates on appropriate case plan of action, including identifying case priority, and evaluating case potential for prosecution.

  • Coordinates medical necessity reviews with Medical Directors (as needed), educates Medical Directors on case issues (as needed), represents current findings, and coordinates medical necessity and appropriateness decisions.

  • Identifies fraudulent billing problems that can be resolved through claim system editing, and forwards supporting documentation with potential cost savings, to upper management for consideration.

  • Creates reports by using the anti-fraud software (STARS) to identify new potential high dollar fraud cases.

  • Also uses other types of research tools to identify new potential fraud cases.
  • Performs other duties as assigned

  • Complies with all policies and standards
Education/Experience: Bachelor’s Degree in nursing or equivalent work experience
  • Three years recent acute care, or managed care experience
  • One year experience in Quality Management, Credentialing Certification, Medical/Professional Review, Retrospective Review, Prospective Review, Concurrent Review, or SIU desired

License/Certification: Must have and maintain current, valid and unrestricted California Registered Nurse license

Government Security/Clearance/Citizenship Requirements:

Our Comprehensive Benefits Package: Flexible work solutions including remote options, hybrid work schedules and dress flexibility, Competitive pay, Paid time off including holidays, Health insurance coverage for you and your dependents, 401(k) and stock purchase plans, Tuition reimbursement and best-in-class training and development.

Pay Range: $25.44 - $45.76 per hour

Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law.

Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.

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