[Hiring] 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.