Detect and audit aberrant billing patterns in claims and clinical docs.
Perform pre- and post-payment reviews of medical records per guidelines and CMS.
Identify schemes like cloning, upcoding, and unbundling in provider data.
Translate audit findings into education for Oscar teams.
Build evidentiary files for recovery, legal action, or referrals.
Remote role; open to AZ, FL, GA, TX; occasional travel.

🎯 Requirements

Active, unrestricted RN license.
3+ years direct patient care clinical experience; case management a bonus.
2+ years in Medical Review, Utilization Management, or CDI with forensic expertise.
Experience conducting forensic medical audits validating CPT/HCPCS/ICD-10 code support.

🎁 Benefits

Medical, dental, and vision benefits.
11 paid holidays, paid sick time, paid parental leave.
401(k) plan participation; life and disability insurance.
Unlimited vacation program and annual performance bonuses.
Paid wellness time and reimbursements.

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