Nurse Specialist II

Qlarant; United States; Sur place; USD 65 000 - 90 000; Plein temps

Résumé du poste

Qlarant seeks a qualified reviewer to perform medical record and claims reviews for Medicare, Medicaid, and other claims data, ensuring guidelines are followed and identifying potential overpayments, fraud, waste, and abuse. Position requires RN licensure and a Bachelor’s degree with 2–4 years of experience, Medicare exposure preferred.

Responsibilities include desk reviews, field audits, data entry, reporting, and collaboration with investigators.

Qualifications

• Minimum Bachelor's Degree required.
• 2-4 years of experience required; 5-7 years preferred.
• Medical Review experience.
• Medicare experience preferred.
• Current, active and non-restricted RN licensure required.
• Coding certification preferred.

Responsabilités

• 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 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.

Connaissances

RN licensure

Medical record review

Medicare/Medicaid knowledge

Research & analysis

Communication

Formation

Bachelor's Degree

Description du poste

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.

Medicare experience 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.