Nextphase Health Solutions

Job Responsibilities

• Review beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.

• Conduct desk reviews in alignment with applicable contract requirements to identify potential fraud or overpayment.

• Prepare detailed case summaries and provide results to investigators to support the investigative process.

• Perform case-specific or plan-specific data entry and reporting to ensure accuracy and compliance.

Required Qualifications

• Active, non-restricted Registered Nurse (RN) license.

• Strong computer proficiency with excellent written communication skills.

• Demonstrated research and analytical skills.

Preferred Qualifications

• Coding certification (e.g., CPC, CCS, or equivalent).

• Familiarity with Medicaid and Medicare regulations.

• Experience with medical chart review.

• Broad clinical background; experience in Hospice, Home Health, or Skilled Nursing Facility (SNF) review highly beneficial.