[Hiring] Medical Review RN / Nurse Specialist @Orchard

Role Description

The Nurse Specialist – Medical Claims Review role involves working from home within the Continental United States. The position requires superior analytical skills and a proven ability to evaluate medical claims data. The nurses on this team perform medical record and claims review for Medicare, Medicaid, and/or other claims data to ensure that proper guidelines have been followed and assess for potential overpayment, fraud, waste, and abuse.

• Performs medical record and claims review for Medicare, Medicaid, and/or other claims data.
• 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.
• 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.
• 2 - 4 years of experience required in medical review and/or utilization review; 5 - 7 years preferred.
• Medicare or Medicaid experience preferred.

Requirements

• Current, active and non-restricted RN licensure required.

Company Description

Established in 2010, @Orchard LLC, also known as Talent Orchard, has an exceptional reputation, providing staffing solutions to time-sensitive, talent scarcity issues to deliver better talent management ROI.

• Specializes in program talent acquisition and resource management.
• Covers many areas of technical and functional delivery.