Nurse Specialist II

Job 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.

Responsibilities

• 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.

Requirements

• Level of Supervision Received: Plans and arranges own work; works with manager to prioritize projects Education (can be substituted for experience): Minimum Bachelor's Degree preferred, RN license required Work Experience (can be substituted for education): 2 - 4 years of experience in medical claims review required; 5 - 7 years preferred Certification(s): Current, active and non-restricted RN licensure required Coding certification preferred

About Qlarant

For over 50 years, our history has been rooted in commitment to quality improvement for organizations — and quality of life for the people they serve. We began as Delmarva Foundation for Medical Care in 1973 on Maryland’s Eastern Shore as one of the country’s first quality review organizations for the Centers for Medicare and Medicaid. Through the decades, we created entities that became nationally known, including Delmarva Foundation, Health Integrity, and Quality Health Strategies. Today, we’ve brought together these extensive resources and the expertise of more than 500 professionals under one name — Qlarant — serving some of our nation’s most important programs in health, human services, government and insurance & financial services. Qlarant has a strong commitment to protecting the integrity of national and state health care systems in Medicare, Medicaid, and the private sector. In addition, The Qlarant Foundation issues annual grant awards to various programs that provide programs to underserved communities. Qlarant offers a broad range of innovative services: we’re proud to deliver our solutions for Quality Improvement; Fraud, Waste, & Abuse; and Data Sciences & Technology. Our Real-time Predictive Modeling and Data Analytics tools sift through billions of claims and public criminal records to detect aberrant trends and alert users for early investigative and audit actions with high accuracy and performance. We also provide quality review programs, auditing, training, and have an in-house call center ready to meet your needs. Visit www.qlarant.com for further information.