Minimum of 5 years of nursing experience in diverse healthcare settings.
Strong knowledge of clinical documentation and healthcare delivery practices.
Exceptional analytical, investigative, and critical-thinking skills.
Excellent verbal and written communication abilities.
Ability to work independently while collaborating effectively across departments.
Responsibilities
Review and analyze medical records and claims documentation.
Investigate high-risk claims involving potential fraud, waste, or abuse.
Conduct clinical reviews to support investigations and risk assessments.
Evaluate claimant eligibility and provider utilization.
Collaborate with various teams including Care Coordination and Compliance.
Communicate professionally with claimants and healthcare providers.
Prepare referrals for Special Investigation Units.
Benefits
Generous 401k plan with immediate vesting and 100% match up to 6%.
Bonus opportunity based on company metrics and personal performance.
Extensive paid time off including 3 weeks vacation and 12 paid holidays.
Comprehensive health, dental, and vision benefits, along with disability and life insurance.
6 weeks fully-paid parental leave.
Tuition reimbursement program for career advancement.
Paid time off for volunteering and organized company volunteer opportunities.
Robust wellness program supporting various aspects of well-being.
Full Job Description
Claims Fraud Clinical Analyst (RN) Protect the Integrity of Long-Term Care Benefits
Are you a Registered Nurse who enjoys investigative work, critical thinking, and complex case analysis? Do you have experience reviewing medical records, evaluating claims, and identifying potential risks within healthcare programs?
We are seeking a Claims Fraud Clinical Analyst (CFCA) to join our Claims Risk Management team. In this role, you will leverage your clinical expertise and analytical skills to help detect, prevent, and minimize fraud, waste, and abuse within a long-term care insurance program.
This position offers a unique opportunity for an experienced RN to move beyond direct patient care and play a key role in protecting benefit integrity while collaborating with clinical, claims, compliance, and investigative teams.
What You'll Do
Review and analyze medical records, benefit eligibility assessments, independent medical examinations, and claims documentation.
Investigate high-risk claims and referrals involving potential fraud, waste, or abuse.
Conduct clinical reviews to support active investigations and risk assessments.
Evaluate claimant eligibility, provider utilization, billing patterns, and care plans.
Collaborate with Care Coordination, Claims, Customer Service, Compliance, and Risk Management teams.
Communicate professionally with claimants, healthcare providers, attorneys, and internal stakeholders.
Prepare referrals for Special Investigation Units and forensic investigation teams.
Identify trends, risks, and opportunities to strengthen fraud prevention efforts.
Maintain professional licensure and complete required continuing education.
Minimum of 5 years of nursing experience in a variety of healthcare settings.
Strong knowledge of clinical documentation and healthcare delivery practices.
Exceptional analytical, investigative, and critical-thinking skills.
Excellent verbal and written communication abilities.
Ability to work independently while collaborating effectively across departments.
Preferred
Long-term care, home health, or case management experience.
Experience in claims review or insurance operations.
Background investigating fraud, waste, or abuse within healthcare environments.
Knowledge of healthcare regulations, compliance, and risk management practices.
Certified Fraud Examiner (CFE) credential or willingness to obtain certification.
What Makes You Successful
Strong attention to detail and investigative mindset.
Ability to analyze complex medical information and identify potential concerns.
Sound clinical judgment and decision-making abilities.
Confidence communicating with diverse stakeholders in challenging situations.
Ability to manage multiple priorities in a fast-paced environment.
Commitment to customer service and professional excellence.
This position offers the opportunity to make a meaningful impact by protecting valuable long-term care benefits while applying your clinical expertise in a highly specialized role. If you enjoy solving complex problems, reviewing medical documentation, and contributing to fraud prevention and risk management efforts, we encourage you to apply.
Apply today to become part of a team dedicated to safeguarding benefits and supporting program integrity.
Location: Portsmouth, NH
Schedule: Full-time 40 hours, Hybrid 2 days per week in office
What to Expect on Pay:
The salary range for this role is $71,885 - $97,257 per year. We've shared the full range to stay transparent - but most new hires join us between the minimum ($71,885) and the midpoint ($84,571), depending on skills and experience.
Final compensation is based on a mix of factors including qualifications, experience, and education, as well as internal equity and budget considerations.
Generous 401k plan: 100% match of employee's contribution, up to a maximum of 6% salary, vests immediately.
Bonus Opportunity: Qualifying employees can earn an annual bonus based on company metrics and personal performance.
Lots of paid time off:3 weeks' vacation, 7 sick days, 3 personal days, and 12 paid holidays!
Competitive benefits include health, dental, vision, disability, life, legal, flexible spending account (FSA) and Health Savings Account (HSA) options.
6 weeks fully-paid parental leave
Tuition reimbursement program to support career goals.
Corporate giving and matching gifts program.
Volunteer program: Paid time off to volunteer and company-organized volunteering opportunities.
A wide variety of personal, professional, and career development programs.
Comprehensive wellness program offering a variety of resources and activities to help support your well-being in the following areas: career, financial, mental, emotional, physical, social and community.
