Remote Compliance Auditor
Description du poste: • Analyze claims data, medical records, and provider documentation to identify discrepancies, fraud, or non-compliance. • Conduct retrospective case reviews, on-site provider audits, and recipient interviews. • Review billing practices for upcoding, duplicate billing, and unbundling of services using ICD-10, CPT, and HCPCS manuals. • Prepare reports, case findings, and recommend sanctions when violations are identified. • Coordinate and participate in teleconferences, hearings, and legal proceedings with the Office of General Counsel and other agencies. • Respond to provider complaints and compliance inquiries via hotline, email, and official reports. • Maintain case tracking systems and contribute to policy recommendations and process improvements. • Travel as needed for on-site reviews, meetings, and training. Exigences: • Registered Nurse (RN) license (required) • Experience with claims analysis, medical records review, and compliance investigations. • Knowledge of MA regulations, medical billing, and fraud detection. • Proficiency in Microsoft Office • Strong written and verbal communication skills for reporting and testimony. • Ability to work independently, maintain confidentiality, and manage case files efficiently. • Must be able to travel to Harrisburg, PA for training Avantages:
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