The auditor/investigator conducts impartial audits and investigations into claims to ensure integrity, accuracy, and compliance with regulations. They also identify fraud, waste, and abuse while providing recommendations to management for claim resolution.
The Quality Review Specialist facilitates evaluations to assess the quality and safety of services provided to individuals with intellectual and developmental disabilities. They also provide technical assistance, generate reports, and collaborate with stakeholders to ensure compliance with regulations and continuous service improvement.
Performs medical record and claims reviews to identify potential fraud, waste, and abuse within Medicare and Medicaid programs. Conducts desk reviews, field audits, and provides case summaries to support investigative processes.
The Nurse Specialist II performs medical record and claims reviews to identify potential fraud, waste, and abuse within Medicare and Medicaid programs. They also conduct field audits, provide case summaries for investigators, and participate in legal proceedings as necessary.
