Fraud, Waste and Abuse (FWA) Clinical Review Registered Nurse

About Our CompanyWe’re a physician-led, patient-centric network committed to simplifying health care and bringing a more connected kind of care.Our primary, multispecialty, and urgent care providers serve millions of patients in traditional practices, patients' homes and virtually through VillageMD and our operating companies Village Medical, Village Medical at Home, Summit Health, CityMD, and Starling Physicians.When you join our team, you become part of a compassionate community of people who work hard every day to make health care better for all. We are innovating value-based care and leveraging integrated applications, population insights and staffing expertise to ensure all patients have access to high-quality, connected care services that provide better outcomes at a reduced total cost of care.Please Note: We will only contact candidates regarding your applications from one of the following domains: @summithealth.com, @citymd.net, @villagemd.com, @villagemedical.com, @westmedgroup.com, @starlingphysicians.com, or @bmctotalcare.com.Job DescriptionJoin VillageMD as a Fraud, Waste, and Abuse (FWA) Clinical Review Registered NurseACO Operations How you can make a differenceThe Fraud, Waste, and Abuse (FWA) Clinical Review RN supports ACO Operations by performing comprehensive clinical reviews to identify, prevent, and address potential fraud, waste, and abuse across value-based care arrangements. This role partners closely with internal teams and market stakeholders to ensure accurate documentation, appropriate utilization, and compliance with regulatory and contractual requirements.The ideal candidate brings strong acute and post-acute care expertise, excels in clinical documentation, working remotely both independently and collaboratively, and serves as a trusted clinical liaison across multiple markets.FWA Clinical Review RN Key ResponsibilitiesConduct detailed clinical record reviews (inpatient and outpatient based) to identify potential fraud, waste, and abuse in accordance with CMS, payer, and organizational regulations and guidelinesAssess medical necessity, appropriateness of services, coding accuracy, and documentation integrityCollaborating with Clinical Care Team Members, Compliance, Coding, Quality, and Market teams to resolve identified issues and corrective actionsServe as a clinical liaison and facilitate interdisciplinary meetings between corporate ACO Operations and market stakeholders.Provide clinical insight and education related to documentation standards, utilization patterns, value-based care, and best practice principlesPrepare clear, concise summaries and reports of review findings for leadership and regulatory purposesSupport audits, investigations, and monitoring activities as neededMaintain up-to-date knowledge of all FWA regulations including CMS guidance and compliance requirementsWork independently in a fully remote environment while meeting productivity and quality standardsQualificationsActive, unrestricted Registered Nurse (RN) license5–7 years of clinical experience with strong exposure to:Inpatient hospital clinical documentationAmbulatory/office-based clinical documentationDemonstrated experience in clinical record review, utilization review, compliance, or audit functionsStrong understanding of medical necessity, documentation standards, and healthcare regulationsExcellent written and verbal communication skillsAbility to collaborate across teams and serve as a liaison among all audiencesProficiency with electronic health records (EHRs) and clinical documentation systems including data capture, data mining and reportingCohesive work with other clinical and administrative teamsComfortable working independently in a 100% remote roleExperience and skills for successStrong knowledge of fraud, waste, and abuse regulations, clinical review, compliance, or risk adjustmentFamiliarity with ACOs, Medicare, Medicare Advantage, and/or other Value-Based Care and Advanced Care modelsKnowledge of CMS regulations and compliance audit processesPrior experience supporting multi-market or enterprise-level operationsA collaborative communication style and the ability to coordinate interdepartmentallyPassion for data driven quality patient careThe ability to be flexible in an ambiguous and dynamic environmentA service orientation and a “can do” attitudeA willingness to learn on your own and take initiativeThe base compensation range for this role is $78,000 - $98,000 per year depending on experience. At VillageMD, compensation is based on several factors including, but not limited to education, work experience, certifications, location, etc. The selected candidate will be eligible for a valuable company benefits plan, including health insurance, dental insurance, life insurance, and access to a 401k plan.About Our CommitmentTotal Rewards at VillageMDOur team members are essential to our mission to reshape healthcare through the power of connection. VillageMD highly values the critical role that health and wellness play in the lives of our team members and their families. Participation in VillageMD’s benefit platform includes Medical, Dental, Life, Disability, Vision, FSA coverages and a 401k savings plan.Equal Opportunity EmployerOur Company provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to, and does not discriminate on the basis of, race, color, religion, creed, gender/sex, sexual orientation, gender identity and expression (including transgender status), national origin, ancestry, citizenship status, age, disability, genetic information, marital status, pregnancy, military status, veteran status, or any other characteristic protected by applicable federal, state, and local laws.Safety DisclaimerOur Company cares about the safety of our employees and applicants. Our Company does not use chat rooms for job searches or communications. Our Company will never request personal information via informal chat platforms or unsecure email. Our Company will never ask for money or an exchange of money, banking or other personal information prior to the in-person interview. Be aware of potential scams while job seeking. Interviews are conducted at select Our Company locations during regular business hours only. For information on job scams, visit, https://www.consumer.ftc.gov/JobScams or file a complaint at https://www.ftccomplaintassistant.gov/.

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