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

📋 Description

• • VillageMD is seeking a dedicated and experienced Fraud, Waste, and Abuse (FWA) Clinical Review Registered Nurse to join our ACO Operations team. This pivotal role is designed for a clinical professional who is passionate about ensuring the integrity of value-based care arrangements through meticulous review and proactive identification of potential FWA.
• • As an FWA Clinical Review RN, you will be instrumental in safeguarding the financial and ethical health of our organization by conducting comprehensive clinical record reviews. Your expertise will be crucial in identifying instances of fraud, waste, and abuse within our diverse value-based care programs, adhering strictly to the guidelines set forth by CMS, payers, and internal organizational policies.
• • Your responsibilities will extend to assessing the medical necessity of services rendered, evaluating the appropriateness of care delivery, verifying coding accuracy, and ensuring the integrity of clinical documentation. This detailed examination is fundamental to upholding the standards of value-based care and preventing financial leakage.
• • A significant aspect of this role involves close collaboration with a variety of internal teams. You will work hand-in-hand with Clinical Care Team Members, Compliance officers, Coding specialists, Quality improvement professionals, and Market-based teams to address any identified issues. Your insights will drive the implementation of corrective actions and continuous improvement initiatives.
• • You will also serve as a vital clinical liaison, facilitating clear and effective communication between the corporate ACO Operations department and stakeholders across multiple markets. This bridge-building function ensures that clinical perspectives are understood and integrated into operational strategies.
• • Providing clinical insight and education is another key component of this position. You will educate stakeholders on best practices related to documentation standards, optimal utilization patterns, the principles of value-based care, and other relevant clinical best practices. This educational outreach is essential for fostering a culture of compliance and excellence.
• • The role requires you to prepare clear, concise, and accurate summaries and reports detailing your review findings. These reports will be critical for leadership decision-making and for fulfilling regulatory reporting requirements.
• • You will actively support various audits, investigations, and monitoring activities as directed, contributing your clinical knowledge to ensure thoroughness and accuracy.
• • Maintaining an up-to-date and comprehensive understanding of all FWA regulations, including the latest CMS guidance and compliance requirements, is paramount. This ensures that all reviews and recommendations are current and compliant.
• • This is a fully remote position, demanding a high degree of self-discipline and autonomy. You will be expected to work independently, manage your workload effectively, and consistently meet established productivity and quality standards.
• • The ideal candidate possesses a strong background in acute and post-acute care settings, demonstrating a proven ability to excel in clinical documentation review, remote work environments, and collaborative team settings. You will act as a trusted clinical resource across our various operating markets.
• • Your contributions will directly impact the success of our value-based care models by ensuring compliance, optimizing resource utilization, and protecting the organization from potential financial and reputational risks associated with FWA.
• • This role offers a unique opportunity to leverage your clinical expertise in a dynamic, compliance-focused environment, contributing to VillageMD's mission of delivering high-quality, connected care at a reduced total cost.
• • You will be empowered to make a tangible difference by upholding the highest standards of clinical practice and regulatory adherence, ensuring that our patients receive the best possible care while our organization operates with integrity and efficiency.