Nurse SME - Contingent

• Provides clinical support to other functional areas (e.g., audits, complaints, data analysis, investigations, requests for information, predictive modeling, and vulnerabilities) in need of subject matter expertise.
• Works directly with the client and appropriate stakeholders, health plans, pharmacy benefit managers, other contractors, law enforcement, providers, suppliers, prescribers, and pharmacies to build partnerships, support data sharing, develop tools, and references to support program integrity initiatives.
• Initiates and contributes to the conceptual design, methodologies, and implementation of projects, as well as assist with project execution as needed.
• May provide educational programs as necessary to meet project goals, combat potential fraud, waste, and abuse, and promote high quality, safe, and effective medication use.
• Develop solutions, alternative practices, or strategies to detect and prevent FWA.
• Gather and organize information about a problem to be solved or the procedure or process to be improved.
• Analyze financial, operational, and performance data, information, and other forms of evidence.
• Participate in audit activities, such as performing audits and/or reviews of healthcare services based on billing and medical records, compendia, and criteria to evaluate the appropriateness of the patient encounters.
• Use nursing expertise to translate requirements among other professionals.
• Identify and utilize appropriate techniques in vetting data and information.
• Identify and aid in the development of best practices for conducting audits, analytics, and program vulnerability studies.
• Review and analyze encounter data, fee-for-service claims, enrollment data, prescription drug event records, and other data sources in providing advice, input, and recommendations.

• Active, unrestricted Registered Nurse (RN) license in at least one U.S. state or territory.
• Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related healthcare field required.
• 10 years of clinical and healthcare industry experience, including medical record review, clinical auditing, risk adjustment, payment integrity, quality improvement, or healthcare program oversight.
• Demonstrated expertise in reviewing and interpreting medical records, claims data, encounter data, and clinical documentation.
• Strong knowledge of Hierarchical Condition Categories (HCCs), risk adjustment methodologies, risk score validation, and coding/documentation requirements.
• Experience supporting or conducting Risk Adjustment Data Validation (RADV) audits and reviews.
• Knowledge of Health Risk Assessments (HRAs) and their role in risk adjustment and population health initiatives.
• Experience evaluating and analyzing encounter data for completeness, accuracy, and compliance.
• Working knowledge of CMS STAR Ratings, quality performance measures, and healthcare quality improvement initiatives.
• Familiarity with supplemental benefits, healthcare utilization trends, and member-focused care programs.
• Knowledge of Medical Loss Ratio (MLR) concepts and their impact on healthcare operations and performance.
• Experience identifying potential fraud, waste, abuse, compliance risks, documentation gaps, and operational vulnerabilities through clinical review and data analysis.
• Strong analytical and critical thinking skills with the ability to interpret clinical, operational, and financial data and provide actionable recommendations.
• Experience collaborating with health plans, providers, healthcare organizations, and cross-functional teams to support program objectives.
• Excellent written and verbal communication skills, including the ability to summarize clinical findings and present recommendations to stakeholders.

• Experience supporting healthcare program integrity, fraud, waste, and abuse (FWA) detection and prevention efforts.
• Experience conducting clinical audits, medical record reviews, claims reviews, utilization reviews, or healthcare investigations.
• Knowledge of healthcare reimbursement methodologies, claims processing, and healthcare data analytics.
• Experience working with health plans, providers, suppliers, pharmacies, or other healthcare stakeholders.
• Familiarity with healthcare compliance requirements and quality improvement methodologies.
• Experience developing educational materials, training programs, guidance documents, or best-practice recommendations.
• Professional certifications such as CPHQ, CCM, CPMA, CHC, or other relevant healthcare certifications preferred.
• Experience supporting government, commercial, or managed healthcare programs preferred. 

Salary : $100,000 - $120,000