Nurse Specialist II

Qlarant; United States; On-site; USD 65,000 - 95,000; Full time

Job summary

Qlarant, a not-for-profit organization, seeks a skilled medical record and claims reviewer to ensure compliance with Medicare, Medicaid, and related guidelines. The role focuses on identifying overpayments, fraud, waste, and abuse while supporting investigators with evidence and case summaries.

The position requires a minimum Bachelor’s degree, RN licensure, and 2–4 years of medical review experience; coding certification is preferred.

Qualifications

• Bachelor's degree required.
• RN licensure current and non-restricted.
• Coding certification preferred.
• 2–4 years medical review experience; 5–7 years preferred.

Responsibilities

• Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review or field audits to meet contract requirements and identify evidence of potential overpayment or fraud.
• Consults with benefit integrity investigation experts and pharmacists for guidance.
• Completes case summaries and provides results to investigators to support the investigative process.
• Provides job-specific data entry and reporting for cases.
• Participates in internal and external focus groups and provider onsite visits during audits.
• Testifies at legal proceedings as necessary.
• Provides orientation and training content for job functions.

Skills

Medical record review

Fraud awareness

Case documentation

Education

Bachelor's Degree

RN licensure

Coding certification

Tools

Medicare claims data systems

Job description

Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for underserved communities.

Best People, Best Solutions, Best Results

Job Summary

Performs medical record and claims review for Medicare, Medicaid, and/or other claims data in order to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse with regards to Medicare, Medicaid, and/or other claims.

Essential Functions

• Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.
• Consults with benefit integrity investigation experts and pharmacists for advice and clarification.
• Completes case summaries and provides results to investigators to support the investigative process.
• Provides case specific or plan specific data entry and reporting.
• Participates in internal and external focus groups, as required.
• Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations.
• Testifies at various legal proceedings, as necessary.
• Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions.

Level of Supervision Received

Plans and arranges own work; works with manager to prioritize projects

Education (can be substituted for experience)

Minimum Bachelor's Degree required

Work Experience (can be substituted for education)

2 - 4 years of experience required; 5 - 7 years preferred

Medical Review experience required

Experience with Medicare claims/regulations preferred

Certification(s)

Current, active and non-restricted RN licensure required

Coding certification preferred

Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.

Qlarant is a drug-free workplace. All offers of employment are contingent upon successful completion of pre-employment background and drug screens.