- Conduct in-depth medical reviews through prepayment claims review and post-payment auditing
- Identify potential over-utilization or fraudulent activities
- Assist in the creation of audit tools, policies, procedures, and educational materials
- Serve as a liaison with service operations and provide status updates on claims reviews
- Analyze performance data to identify patterns and trends
- Recommend modifications to medical policy
- Support fraud investigators with medical review expertise
- Mentor other nurse auditors
Microsoft Office