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Best People. Best Solutions. Best Results.®
Nurse Specialist II
Location
United States
Posted
100 days ago
Salary
$64.5K - $95K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Nurse Specialist II
Qlarant
This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description 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. - 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. Qualifications - Minimum Bachelor's Degree required. Requirements - 2 - 4 years of experience required; 5 - 7 years preferred. - Current, active and non-restricted RN licensure required. - Coding certification preferred.
Job Requirements
- Minimum Bachelor's Degree required.
- 2 - 4 years of experience required; 5 - 7 years preferred.
- Current, active and non-restricted RN licensure required.
- Coding certification preferred.
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