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Program Integrity Investigator Jobs in Florida (NOW HIRING)

CES, LLC

Medical Review Nurse III

Saint Augustine, FL · Remote

Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in ...

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Infographic showing various Program Integrity Investigator job openings in Florida as of August 2026, with employment types broken down into 1% As Needed, 82% Full Time, 14% Part Time, and 3% Contract. Highlights an 95% Physical, 1% Hybrid, and 4% Remote job distribution.

Medical Review Nurse III

CES, LLC

Saint Augustine, FL • Remote

Full-time

Posted 11 days ago

Key responsibilities

  • Review medical records and claims data to determine if they meet Medicare and Medicaid guidelines.

  • Coordinate and compile written Investigative Summary Reports upon completion of records review.

  • Work with healthcare professionals, regulatory agencies, and law enforcement to support fraud investigations and program integrity efforts.

Job description

Job Description Summary: 
The Medical Reviewer will utilize Medicare and/or Medicaid rules, regulations, and guidelines in reviewing medical records documentation to determine if a claim meets these requirements. Primarily responsible for conducting clinical reviews of medical records during the course of fraud investigations or other program integrity initiatives such as requests for information or in support of proactive data analysis efforts. Applies Medicare guidelines in making clinical determinations as to the appropriateness of payment coverage. The Medical Reviewer coordinates and compiles the written Investigative Summary Report to the Program Integrity Investigator upon completion of the records review within timelines set by CMS. 
 
Duties/Responsibilities:   
  • Review information contained in Standard Claims Processing System files (e.g., claims history, provider files) to determine provider billing patterns and to detect potentially fraudulent or abusive billing practices or vulnerabilities in Medicare payment policies 
  • Utilize extensive knowledge of medical terminology, ICD-9-CM and ICD-10-CM, HCPCS Level II and CPT coding along with analysis and processing of Medicare claims.  Utilize Medicare and Contractor guidelines for coverage determination 
  • Coordinate and compile written Investigative Summary Reports in conjunction with PI Investigators upon completion of the records review 
  • Uses leadership and communication skill to work with physicians and other health professionals as well as external regulatory agencies and law enforcement personnel 
  • Provide training to staff on medical terminology, reading medical records, and policy interpretation 
  • Provide expert witness testimony as required 
  • Complete assignments in a manner that meets or exceeds the quality assurance goal of 98% accuracy 
  • Maintain chain of custody on all documents and follows all confidentiality and security guidelines 
  • Perform other duties as assigned by the Medical Review Supervisor that contribute to goals and objectives and comply with the Program Integrity Manual and Statement of Work guidelines and CMS directives and regulations 
 
Required qualifications/skills: 
  • Graduate from an accredited school of nursing and has an active license as a Registered Nurse (RN).  
  • Knowledge of, and the ability to correctly identify, Medicare coverage guidelines 
  • Excellent oral and written communication skills 
  • Proficient with Microsoft Word, Excel and Internet applications 
  • Ability to efficiently organize and manage workload and assignments 
  • A minimum of 4 years of utilization/quality assurance review and ICD-9/10-CM/CPT-4 coding experience 
  • At least 4 years' experience in coding and abstracting, working knowledge of Diagnosis Related Groups (DRGs), Prospective Payment Systems, and Medicare coverage guidelines is required 
  • Advanced knowledge of medical terminology and experience in the analysis and processing of Medicare claims, utilization review/quality assurance procedures, ICD-9/10-CM and CPT-4 coding, Medicare coverage guidelines, and payment methodologies (i.e., Correct Coding Initiative, DRGs, Prospective Payment Systems, and Ambulatory Surgical Center), NCPDP and other types of prescription drug claims is required 
  • Ability to read Medicare claims, both paper and electronic, and a basic knowledge of the Medicare claims systems is required 
 
Preferred qualifications/skills: 
  • None  
 
Other: 
  • Must have and maintain a valid driver's license for the associate's state of residence  
  • Travel may be required as necessary, with prior approval. All necessary travel expenses are reimbursable via GSA standards 
  • Must have no adverse actions pending or taken against him/her by any State or Federal licensing board or program; and must have no conflict of interest (COI) as defined in § 1154(b)(1) of the Social Security Act. 
 
Supervisory Responsibilities: 
  • None 
 
Office Equipment (if a WFH position): 
  • A locking cabinet and/or desk appropriate for storing documents and electronic media 
  • A cross-cut or micro-cut (preferred) shredder. 
  • Broadband internet connection  
  • Phone line (land line or cellular)  
 
Physical Requirements: 
  • May require prolonged periods of sitting at a desk, working on a computer and conducting phone interviews