Remote Medical Review Analyst – Registered Nurse (RN) – Advanced Clinical Claims Evaluation, Fraud Detection & Medicare/Medicaid Compliance Specialist

```html About Integrity Management Services, Inc. – Pioneering Integrity in Healthcare Integrity Management Services, Inc. (IntegrityM) is a distinguished woman‑owned, small‑business leader dedicated to safeguarding the nation’s healthcare expenditures. Our mission is to partner with federal, state, and local government health programs to detect, prevent, and mitigate fraud, waste, and abuse. We blend the agility and close‑knit culture of a boutique firm with the robust resources and benefits of a larger organization, creating a workplace where every employee feels valued, empowered, and poised to make a meaningful impact. Our Remote Office model reflects our belief that talent thrives best when given flexibility. Whether you’re a seasoned Registered Nurse seeking a new challenge or an analytical professional with a passion for clinical data, you’ll find a supportive community, cutting‑edge technology, and opportunities for continuous learning at IntegrityM. Why This Role Matters – The Bigger Picture Healthcare fraud costs the United States billions of dollars each year, undermining the quality of care for millions of citizens. As a Medical Review Analyst (RN) , you will be at the front line of this fight, applying your clinical expertise to evaluate medical claims, ensure compliance with Medicare and Medicaid regulations, and protect taxpayer dollars. Your work directly influences the integrity of vital health programs and improves outcomes for patients across the country. Key Responsibilities – What You’ll Do Every Day Under the mentorship of a seasoned Medical Review Manager, you will undertake a diverse set of duties that blend clinical judgment with investigative analysis. Your core responsibilities include, but are not limited to: Comprehensive Medical Record Review: Examine detailed patient charts, clinical notes, and supporting documentation to determine medical necessity, appropriateness of care, and adherence to policy. Clinical Decision‑Making: Apply evidence‑based nursing knowledge to make accurate, defensible payment decisions on claims, referencing current Medicare and Medicaid guidelines. Fraud Detection & Analysis: Utilize sophisticated data‑model outputs, analytics tools, and pattern‑recognition techniques to identify anomalies, potential fraud, and improper billing practices. Research & Policy Interpretation: Stay abreast of evolving national and local health policies, regulatory updates, and statutory requirements; integrate these insights into review determinations. Collaborative Investigation: Partner with fraud investigators, auditors, and legal teams to provide clinical context, answer information requests, and support ongoing investigations. Documentation & Reporting: Produce clear, concise, and well‑structured review reports that detail findings, rationale, and recommended actions for senior leadership. Continuous Improvement: Contribute to process‑enhancement initiatives, suggest workflow optimizations, and share best practices with peers to elevate the overall quality of the review function. Training & Mentorship: Occasionally assist in onboarding new analysts, offering guidance on clinical nuances, system navigation, and organizational standards. Essential Qualifications – The Must‑Haves We are looking for professionals who bring a blend of clinical expertise, analytical rigor, and communication prowess. The following qualifications are non‑negotiable: Active Registered Nurse (RN) License: Must hold a current, unrestricted RN license in the United States. 5–7 Years of Clinical Experience: Demonstrated experience as a bedside RN or other clinical role, with a strong foundation in patient assessment, care planning, and documentation. Medical Review Expertise: Proven track record conducting medical record reviews, evaluating claim eligibility, and applying clinical judgment to determine medical necessity. Medicare/Medicaid Knowledge: In‑depth understanding of federal and state health program policies, coverage criteria, and reimbursement guidelines. Investigative Acumen: Ability to identify red flags, analyze complex data sets, and think critically about potential fraud scenarios. Exceptional Communication Skills: Strong written and verbal abilities, capable of translating clinical findings into clear, concise reports for multidisciplinary audiences. Organizational & Prioritization Skills: Proven capacity to manage multiple cases simultaneously, meet strict deadlines, and maintain accurate documentation. Technological Proficiency: Comfortable using Microsoft Office Suite (Word, Excel, PowerPoint, Outlook) and adaptable to proprietary claim‑review platforms. Preferred Qualifications – The Plus Points While not required, the following experiences and credentials will set you apart from the competition: Bachelor of Science in Nursing (BSN): Formal academic preparation enhances evidence‑based practice and critical thinking. 2+ Years of Direct Clinical Experience: Recent bedside exposure helps maintain current clinical perspectives. Previous Experience in Health‑Care Fraud Detection: Background in fraud, waste, and abuse investigations is highly valued. Certification in Health‑Care Compliance or Fraud Investigation: Examples include Certified Professional in Healthcare Quality (CPHQ) or Certified Fraud Examiner (CFE). Advanced Data Analytics Skills: Familiarity with SQL, SAS, or other analytical software enhances your ability to interrogate large data sets. Core Skills & Competencies – What Success Looks Like Beyond formal qualifications, thriving in this role requires a specific mindset and skill set: Clinical Reasoning: Ability to synthesize patient information, apply nursing standards, and make sound judgments about appropriateness of care. Detail‑Oriented Analysis: Meticulous attention to nuance in documentation, billing codes, and policy language. Ethical Integrity: Unwavering commitment to confidentiality, compliance, and the ethical standards governing healthcare finance. Adaptability: Comfort navigating changing regulations, emerging technologies, and shifting workload demands. Team Collaboration: Strong interpersonal skills to work effectively with investigators, managers, and cross‑functional teams. Problem‑Solving Initiative: Proactive approach to identifying process gaps and recommending solutions. Resilience & Stress Management: Ability to maintain high performance while reviewing potentially sensitive or high‑volume claims. Career Growth & Learning Opportunities IntegrityM invests heavily in the professional development of its workforce. As a Medical Review Analyst, you will have access to: Continuing Education Stipends: Financial support for nursing education, certifications, or relevant coursework. Mentorship Programs: Pairing with senior analysts and managers to accelerate skill acquisition and career trajectory. Cross‑Functional Rotations: Opportunities to experience fraud investigation, compliance, or policy analysis divisions. Leadership Pathways: Clear progression from Analyst to Senior Analyst, Lead Analyst, and eventually Medical Review Manager or Specialty Director. Conference Attendance: Sponsored participation in industry conferences, webinars, and workshops on healthcare fraud, policy, and analytics. Internal Knowledge Hub: Access to a curated library of regulatory updates, best‑practice guides, and case studies. Work Environment & Company Culture Our remote‑first philosophy is built around trust, autonomy, and connectivity. At IntegrityM you will enjoy: Flexible Scheduling: Shape your workday around personal commitments while meeting service level agreements. Collaborative Virtual Spaces: Regular team huddles, video‑conferences, and digital “watercooler” channels foster camaraderie. Results‑Driven Culture: Performance is measured by impact and quality, not by clock‑watching. Diversity & Inclusion: As a woman‑owned business, we champion gender equity, cultural diversity, and inclusive hiring practices. Recognition Programs: Employee of the Quarter, spot‑bonus awards, and peer‑acknowledgment initiatives celebrate achievements. Technology Stack: State‑of‑the‑art secure VPN, cloud‑based analytics platforms, and user‑friendly claim review tools ensure you have the right resources to succeed. Compensation, Perks & Benefits – What We Offer While exact figures are market‑dependent, IntegrityM provides a competitive total‑reward package designed to support your financial, health, and personal well‑being: Base Salary: Competitive, commensurate with experience and expertise, with regular annual reviews. Performance Bonuses: Incentive payouts tied to quality metrics, case throughput, and fraud‑prevention outcomes. Comprehensive Health Benefits: Medical, dental, vision, and prescription coverage, with options for dependents. Retirement Savings: 401(k) plan with company match, helping you build long‑term financial security. Paid Time Off (PTO): Generous vacation, sick days, and paid holidays to recharge and maintain work‑life balance. Remote Work Stipend: Annual allowance for home‑office equipment, ergonomic furniture, and high‑speed internet. Professional Development: Tuition reimbursement, certification fees coverage, and access to e‑learning platforms. Employee Assistance Program (EAP): Confidential counseling, mental‑health resources, and wellness coaching. Recognition & Celebration: Quarterly virtual events, team‑building challenges, and seasonal appreciation gifts. Application Process – Join the Fight Against Healthcare Fraud Ready to leverage your nursing expertise to protect the integrity of the nation’s health programs? Follow these steps to apply: Visit our secure application portal via the link below. Complete the online questionnaire and upload your updated résumé, copy of RN license, and any relevant certifications. Submit a brief cover letter highlighting your experience in medical review, fraud detection, and why you’re excited about a remote role at IntegrityM. Our recruiting team will review your submission and contact you within 5–7 business days for a preliminary interview. Successful candidates will advance to a panel interview with the Medical Review Manager and a senior compliance specialist. Upon selection, a background check and drug screening will be completed before an official offer is extended. Take the Next Step – Apply Today! If you are a diligent, detail‑oriented RN with a passion for clinical analytics and a desire to make a tangible difference in public health, we want to hear from you. Join Integrity Management Services, Inc. and become a vital part of a mission‑driven team that values expertise, integrity, and growth. Apply now and help shape a fraud‑free future for America’s healthcare system. ``` Apply for this job