Remote Medical Review RN — Utilization & Compliance

Orchard LLC; Chicago (IL); On-site; USD 70,000 - 100,000; Full time

Job summary

Orchard LLC is seeking a Medical Review RN / Nurse Specialist II to perform medical record and claims review for Medicare, Medicaid and other data, while working from home across the Continental United States.

You will review cases for potential overpayment, fraud, waste, and abuse, prepare case summaries, and coordinate with investigators, benefit integrity experts, and pharmacists.

Qualifications

• Bachelor's degree in Nursing or related field.
• 2–4 years of medical review experience.
• At least 1 year of healthcare experience in utilization reviews/management.
• ICD-9 coding, CPT coding, and knowledge of Medicare/Medicaid regulations preferred.
• CMS, State Medicaid, and OIG/FBI or similar agency experience preferred.
• Current, active RN licensure without restrictions.

Responsibilities

• Reviews beneficiary, provider, and pharmacy cases for potential overpayment, fraud, waste, and abuse.
• Completes desk reviews or field audits to meet contract requirements and identify evidence of 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 case-specific data entry and reporting.
• Participates in internal and external focus groups and provider onsite visits as required.
• Testifies at legal proceedings as necessary.
• Assists in training content development and program resources.

Skills

Nursing

Medical review

Healthcare experience

Education

Bachelor's degree in Nursing

Tools

ICD-9 coding

CPT coding

CMS/Medicaid rules

Job description

Orchard LLC is seeking a Medical Review RN / Nurse Specialist II to perform medical record and claims review for Medicare, Medicaid and other data, while working from home across the Continental United States.

You will review cases for potential overpayment, fraud, waste, and abuse, prepare case summaries, and coordinate with investigators, benefit integrity experts, and pharmacists.