[Hiring] Medical Review RN / Nurse Specialist @Orchard

Role Description

The client is seeking an experienced Medical Review RN (Nurse Specialist) to join their Investigation clinical team. The role requires superior analytical skills and a proven ability to evaluate medical claims data. If you love digging into the data, this is the perfect job for you!

• Performs medical record and claims review for Medicare, Medicaid, and/or other claims data to ensure that proper guidelines have been followed and assesses for potential overpayment, fraud, waste, and abuse.
• 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.
• 2 - 4 years of experience required in Medical Review and/or Utilization Management; 5 - 7 years preferred.
• Medicare or Medicaid experience preferred.
• Current, active and non-restricted RN licensure required.

Requirements

• Experience in Medical Review and/or Utilization Management.
• Ability to evaluate medical claims data.
• Strong analytical skills.