Nurse Specialist II at Qlarant

United States

$57.512k - $85.839k

<div><div><div><div><span data-teams="true" data-pasted="true"><p><span style="font-size: inherit;">Qlarant is a not-for-profit corporation that partners with public and private sectors to create high quality, safe, and efficient delivery of health care and human services programs. We have multiple lines of business including population health, utilization review, managed care organization quality review, and quality assurance for programs serving individuals with developmental disabilities. Qlarant is also a national leader in fighting fraud, waste and abuse for large organizations across the country. In addition, our Foundation provides grant opportunities to those with programs for underserved communities.</span></p><p><span style="font-size: inherit;"><strong>Best People, Best Solutions, Best Results</strong></span></p></span><p id="isPasted"><strong><span style="color: rgb(0, 0, 0);">Job Summary:</span></strong></p><p><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">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.&nbsp;</span></p><p><span style="color: rgb(0, 0, 0); font-family: arial, sans-serif; font-size: 14px;"><strong>Essential Functions:</strong></span></p><ul><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Reviews beneficiary, provider, and/or pharmacy cases for potential overpayment, fraud, waste, and abuse.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Completes desk review or field audits to meet applicable contract requirements and to identify evidence of potential overpayment or fraud.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Consults with benefit integrity investigation experts and pharmacists for advice and clarification.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Completes case summaries and provides results to investigators to support the investigative process.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Provides case specific or plan specific data entry and reporting.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Participates in internal and external focus groups, as required.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Participates in provider onsite visits and beneficiary interviews, as required, for field audits/investigations.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Testifies at various legal proceedings, as necessary.</span></li><li style="margin-top: 0in; margin-right: 0in; margin-bottom: 8pt; font-size: 11pt; font-family: Calibri, sans-serif; line-height: 1;"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Provides job-specific orientation and training, as needed. Helps develop training content, resources, and programs specific to job functions.</span></li></ul><p><span style="color: rgb(0, 0, 0);"><strong>Level of Supervision Received:</strong><br>Plans and arranges own work; works with manager to prioritize projects</span></p><p><span style="color: rgb(0, 0, 0);"><strong>Education (can be substituted for experience):</strong><br>Minimum Bachelor&#39;s Degree required</span></p><p><span style="color: rgb(0, 0, 0);"><strong>Work Experience (can be substituted for education):</strong><br>2 - 4 years of experience required; 5 - 7 years preferred</span><br><span style="color: rgb(0, 0, 0);">Medical claims review experience required</span><br><span style="color: rgb(0, 0, 0);">Experience and knowledge3 of Medicare/Medicaid preferred</span></p><p><span style="color: rgb(0, 0, 0);"><strong>Certification(s):</strong><br><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Current, active and non-restricted RN licensure required</span></span><br><span style="color: rgb(0, 0, 0);"><span style="font-size: 14px; font-family: arial, sans-serif; color: black;">Coding certification preferred</span></span></p><span data-teams="true" data-pasted="true"><p style="text-align: center;"><span style="font-size: inherit;">Qlarant is an Equal Opportunity Employer of Minorities, Females, Protected Veterans, and Individuals with Disabilities.</span></p><p style="text-align: center;"><span style="font-size: inherit;">Qlarant is a drug-free workplace. All offers of employment are contingent upon successful completion of pre-employment background and drug screens.</span></p></span></div></div></div></div>