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Nurse Specialist II
Location
United States
Posted
1 day ago
Salary
$56.1K - $83.7K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Nurse Specialist II
Qlarant
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 (can be substituted for experience). - 2 - 4 years of experience required; 5 - 7 years preferred. - Medical Review or Utilization Management experience preferred. - Medicare/Medicaid experience preferred. Requirements - Current, active and non-restricted RN licensure required. - Coding certification preferred. Benefits - 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.
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