Fraud, Waste and Abuse (FWA) Clinical Review Registered Nurse

Summit Health•New York, NY

11d•$78,000 - $98,000•Remote

About The Position

Join VillageMD as a Fraud, Waste, and Abuse (FWA) Clinical Review Registered Nurse ACO Operations How you can make a difference The Fraud, Waste, and Abuse (FWA) Clinical Review RN supports ACO Operations by performing comprehensive clinical reviews to identify, prevent, and address potential fraud, waste, and abuse across value-based care arrangements. This role partners closely with internal teams and market stakeholders to ensure accurate documentation, appropriate utilization, and compliance with regulatory and contractual requirements. The ideal candidate brings strong acute and post-acute care expertise, excels in clinical documentation, working remotely both independently and collaboratively, and serves as a trusted clinical liaison across multiple markets.

Requirements

Active, unrestricted Registered Nurse (RN) license
5–7 years of clinical experience with strong exposure to:
Inpatient hospital clinical documentation
Ambulatory/office-based clinical documentation
Demonstrated experience in clinical record review, utilization review, compliance, or audit functions
Strong understanding of medical necessity, documentation standards, and healthcare regulations
Excellent written and verbal communication skills
Ability to collaborate across teams and serve as a liaison among all audiences
Proficiency with electronic health records (EHRs) and clinical documentation systems including data capture, data mining and reporting
Cohesive work with other clinical and administrative teams
Comfortable working independently in a 100% remote role

Nice To Haves

Strong knowledge of fraud, waste, and abuse regulations, clinical review, compliance, or risk adjustment
Familiarity with ACOs, Medicare, Medicare Advantage, and/or other Value-Based Care and Advanced Care models
Knowledge of CMS regulations and compliance audit processes
Prior experience supporting multi-market or enterprise-level operations
A collaborative communication style and the ability to coordinate interdepartmentally
Passion for data driven quality patient care
The ability to be flexible in an ambiguous and dynamic environment
A service orientation and a “can do” attitude
A willingness to learn on your own and take initiative

Responsibilities

Conduct detailed clinical record reviews (inpatient and outpatient based) to identify potential fraud, waste, and abuse in accordance with CMS, payer, and organizational regulations and guidelines
Assess medical necessity, appropriateness of services, coding accuracy, and documentation integrity
Collaborating with Clinical Care Team Members, Compliance, Coding, Quality, and Market teams to resolve identified issues and corrective actions
Serve as a clinical liaison and facilitate interdisciplinary meetings between corporate ACO Operations and market stakeholders.
Provide clinical insight and education related to documentation standards, utilization patterns, value-based care, and best practice principles
Prepare clear, concise summaries and reports of review findings for leadership and regulatory purposes
Support audits, investigations, and monitoring activities as needed
Maintain up-to-date knowledge of all FWA regulations including CMS guidance and compliance requirements
Work independently in a fully remote environment while meeting productivity and quality standards