Pre-Payment Review Nurse Consultant
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Job Description
OIG Nurse Consultant at Gainwell overseeing Medicaid pre-payment activities. Conducting compliance reviews to combat fraud, waste, and abuse in the Medicaid program.
Responsibilities:
- Conducting clinical and financial pre-payment compliance reviews to detect, combat, and eliminate fraud, waste, and abuse in the Medicaid program.
- Consulting on the development and implementation of pre‑payment review policies and guidelines that support OIG program objectives.
- Perform comprehensive medical record reviews and analyze complex datasets and systems.
- Develop, establish, and implement pre‑payment review criteria across multiple service areas.
- Process pre‑payment reviews according to medical necessity criteria, administrative code, and other requirements.
Requirements:
- Current Wisconsin Registered Nurse license issued by the Wisconsin Department of Safety and Professional Services.
- Knowledge of current medical concepts, practices, and techniques.
- Ability to assess statistical data and reports related to health service utilization patterns.
- Knowledge of laws, statutes, regulations, and rules related to the state Medicaid program.
- Knowledge of federal and state legislation pertaining to Title XIX, Title XVIII, Title XX, and Title III.
- Ability to incorporate medical knowledge and experience into the development of medical policy, administrative rules, and medical standards.
- Ability to develop standards and guidelines for monitoring medical practice patterns.
- Thorough knowledge of Medicaid-covered services and reimbursement policy for analysis, recommendation development, and implementation.
- Ability to use medical and financial records, claims, and claims data to obtain documentation supporting audit or investigative findings.
- Knowledge of Generally Accepted Auditing Standards (GAAS).
- Skill in using computer-accessible databases to support audit activities and technology used for pre-payment review audits, including reviewing and analyzing computer-generated reports.
- Extensive knowledge of hardware, software, and networking technologies relevant to healthcare industry changes.
- Knowledge of program, financial, and accounting systems used by healthcare entities, including patient account management, billing processes, and reimbursement procedures.
- Understanding of governmental and industry accounting and auditing standards or audit guides used to audit healthcare providers.
- Ability to organize, prepare, summarize, and present information gathered during audits or investigations in a clear and usable manner to support valid findings and conclusions.
- Extensive knowledge of technical writing, publication organization, preparation, and formatting.
- Ability to clearly express the State’s position on Medicaid issues—both orally and in writing—in audit reports, investigative reports, exit conferences, and departmental meetings.
- Knowledge of records maintained by healthcare providers and the ability to inspect medical records, patient charts, financial statements, transaction documentation, invoices, payroll records, and claims.
Benefits:
- generous, flexible vacation policy
- 401(k) employer match
- comprehensive health benefits
- educational assistance
- leadership and technical development academies
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