Nurse Specialist II
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Job Description
Nurse Specialist II reviewing Medicare and Medicaid records and claims for Qlarant, a healthcare-programs nonprofit. Identifying overpayments, fraud, waste, and abuse through audits and investigations.
Responsibilities:
- Perform medical record and claims review for Medicare, Medicaid, and/or other claims data
- Ensure proper guidelines have been followed and assess potential overpayment, fraud, waste, and abuse
- Review beneficiary, provider, and/or pharmacy cases
- Complete desk reviews or field audits to meet contract requirements and identify evidence of potential overpayment or fraud
- Consult with benefit integrity investigation experts and pharmacists
- Complete case summaries and provide results to investigators
- Perform case-specific or plan-specific data entry and reporting
- Participate in internal and external focus groups as required
- Participate in provider onsite visits and beneficiary interviews for field audits/investigations as required
- Testify at legal proceedings as necessary
- Provide job-specific orientation and training
- Help develop training content, resources, and programs
- Plan and arrange own work with manager collaboration to prioritize projects
Requirements:
- Minimum Bachelor's Degree required; can be substituted for experience
- 2–4 years of work experience required; 5–7 years preferred
- Current, active, and non-restricted RN licensure required
- Coding certification preferred
- Successful completion of pre-employment background and drug screens
Benefits:
- Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities
- Drug-free workplace
- Employment offers contingent upon successful completion of pre-employment background and drug screens
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