Nurse SME - Contingent

*This position is contingent upon the successful award of the associated contract. Employment is not guaranteed until the contract is awarded, and the position is officially activated. Job responsibilities and requirements are subject to change.

Position: Nurse Subject Matter Expert (SME)
Location: Remote

About J29

J29 is an employee centered healthcare management consulting company that specializes in processing, reviewing, and analyzing medical claims, records, disputes, and audits. Established in 2017, J29 prides itself on its employee centric culture and high employee retention rates that allow us to ensure that we are creating a working environment that prioritizes the employee experience. Our team brings corporate performance that stretches to various areas where we can provide our clinical, healthcare policy, and compliance expertise through our support to health and human service programs at the State, Federal, and Commercial levels.   

Overview
J29 is seeking a highly experienced Nurse Subject Matter Expert (SME) in support of an potential upcoming contract. The Nurse SME will serve as a senior clinical resource, providing subject matter expertise in support of program integrity initiatives, audits, investigations, data analysis, healthcare reviews, fraud, waste, and abuse (FWA) prevention efforts. This individual will collaborate with internal teams and external stakeholders to evaluate healthcare data, review medical records and claims, identify vulnerabilities, and develop recommendations that support compliance, quality, and operational effectiveness. The Nurse SME will leverage extensive clinical experience and analytical expertise to support project objectives and improve healthcare program outcomes.

Role & Responsibilities
- Provides clinical support to other functional areas (e.g., audits, complaints, data analysis, investigations, requests for information, predictive modeling, and vulnerabilities) in need of subject matter expertise.

- Works directly with the client and appropriate stakeholders, health plans, pharmacy benefit managers, other contractors, law enforcement, providers, suppliers, prescribers, and pharmacies to build partnerships, support data sharing, develop tools, and references to support program integrity initiatives.

- Initiates and contributes to the conceptual design, methodologies, and implementation of projects, as well as assist with project execution as needed.

- May provide educational programs as necessary to meet project goals, combat potential fraud, waste, and abuse, and promote high quality, safe, and effective medication use.

- Develop solutions, alternative practices, or strategies to detect and prevent FWA.

- Gather and organize information about a problem to be solved or the procedure or process to be improved.

- Analyze financial, operational, and performance data, information, and other forms of evidence.

- Participate in audit activities, such as performing audits and/or reviews of healthcare services based on billing and medical records, compendia, and criteria to evaluate the appropriateness of the patient encounters.

- Use nursing expertise to translate requirements among other professionals.

- Identify and utilize appropriate techniques in vetting data and information.

- Identify and aid in the development of best practices for conducting audits, analytics, and program vulnerability studies.

- Review and analyze encounter data, fee-for-service claims, enrollment data, prescription drug event records, and other data sources in providing advice, input, and recommendations.

Experience / Expertise
- Active, unrestricted Registered Nurse (RN) license in at least one U.S. state or territory.

- Bachelor's degree in Nursing, Healthcare Administration, Public Health, or a related healthcare field required.

- 10+ years of clinical and healthcare industry experience, including medical record review, clinical auditing, risk adjustment, payment integ